The inter-relationship between formal and informal care: a study in France and Israel

Who Cares for Older Adults? A Cross-National Study of Care Sources for Older Adults With Functional Limitations and Associated Determinants

The study compared care source typologies for older adults in China and the United States. Data from the 2014 U.S. Health and Retirement Study and the 2013 China Health and Retirement Longitudinal Study were used. The respondents included community-dwelling older adults aged 65 years or older with at least one limitation in activities of daily living (ADLs) or instrumental ADLs (IADLs) (NChina = 2476, NUS = 2898). Respondents reported whether they received assistance from spouse, child/grandchild, relatives, others, and formal helpers. Latent class analysis and multinomial logistic regression were applied. Four classes were identified in China and the U.S, separately. In both countries, ADLs and IADLs were strong determinants of care source typologies. Care sources were more diverse and included formal assistance among older Americans. Older Chinese relied largely on their spouses and children/grandchildren for support. Policy efforts are needed to expand formal long-term services and supports, particularly in China.

Gendered Trends in Formal and Informal Care Utilization Among Older Adults in South Korea

Drawing on data from two waves of the Korean Longitudinal Study of Ageing (2010 and 2018), this study examined how community-dwelling older men and women (65+) with functional limitations utilized formal and informal sources of care and how their patterns of care utilization changed over time. The usage patterns of formal and informal caregiving services were categorized into three groups: (a) informal help only, (b) formal-informal mix, and (c) no help from either. More men and women used both formal and informal help for their care needs in 2018 than in 2010 (15% compared to 7%). The proportion of older men who relied on informal help only remained similar across survey years, whereas a smaller proportion of older women relied on informal help only in 2018. Although formal care use has been expanded in South Korea, older men continue to utilize help from their families. However, for older women, the proportion who did not receive any help increased - despite an increase in formal care utilization. These findings highlight the importance of considering gendered resources in caregiving in Korea.

The Impact of Informal Care on Healthcare Utilization of Older Adults with Functional Limitations in China

Our study examines the impact of informal care on healthcare utilization, focusing on caregiver types, urban-rural, and gender differences. Analyzing data from the China Health and Retirement Longitudinal Study and using fixed effects models, we discovered complementary effects between informal care and healthcare. Specifically, spousal care increased inpatient care use, adult child care boosted both inpatient and outpatient use, and dual care from children and spouses showed the most significant impact on healthcare use. The association between informal care and healthcare use varied across gender or urban-rural residence. Our findings highlight the importance of caregivers in accessing healthcare services.

The impact of formal care provision on informal care receipt for people over 75 in England

In this study, we examine the relationship between formal care provision and informal care receipt from within the household for people over 75 years old using data from the British Household Panel Survey between 1991 and 2009. To address potential concerns about endogeneity of formal care we use a 'spatial lag' instrumental variable. We find a negative and statistically significant effect of formal care provision on informal care receipt from within the household, suggesting a substantial degree of substitutability between these two modes of care. These findings provide grounds for estimates of savings in the cost of informal care enabled by spending on formal care, which is important in light of the effects of the caregiving burden and associated responsibilities on carer's labour market participation.

Home care and quality of life among community-dwelling dependent older adults in Israel: a multiple mediator model

PURPOSE

To examine the association between home care provision (combined paid formal home care and non-paid family-only home care) versus non-paid family-only home care with quality of life (QoL) of older adults, as well as the mediating effects of loneliness, social isolation and satisfaction with family relationships and support.

METHODS

A convenience sample of 360 Israeli dependent adults aged 65 + responded to questionnaires. Using bootstrapping, we tested the strength and significance of the conditional indirect effects of the four simultaneous mediators.

RESULTS

Using combined home care provision (paid formal home care and non-paid family-only home care) versus non-paid family-only home care for older adults was associated with lower QoL of care-recipients (B = - 4.57, t = - 2.24, p = 0.001, 95% CI - 8.58, - 0.56; R2 = 0.37), and was fully and strongly mediated by feelings of loneliness (B = - 1.92, p = 0.001, 95% CI - 3.66, - 0.79), social isolation (B = - 0.54, p = 0.001, 95% CI - 1.47, - 0.07) and satisfaction with family support (B = - 1.09, p = 0.001, 95% CI - 2.57, - 0.16). However, the indirect effect through satisfaction with family relationships was not significant. The highest proportion of the indirect effect size was (B = 0.42, 95% CI 0.13, 1.97) for loneliness, followed by satisfaction with family support (B = 0.23, 95% CI 0.01, 1.07), and social isolation (B = 0.11, 95% CI 0.01, 0.66), respectively.

CONCLUSIONS

Using combined formal home care might reduce the QoL of care-recipients by increasing their feelings of loneliness, social isolation and reduced perceived family support. Practitioners should encourage family members to continue with family regular support and contact alongside the use of formal home care in order to maintain satisfaction and QoL of older relatives.

Comparative Analysis of Gender and Age Patterns in Informal Care Received among Disabled Older Adults: A Cross-National Study across the United States, Mexico, China, and Indonesia

This paper examines cross-national differences by gender and age in receipt and sources of help for limitations with activities of daily living or instrumental activities of daily living among older adults in the United States, Mexico, China, and Indonesia. Respondents aged 50 + from the Health and Retirement Study, Mexican Health and Aging Study, China Health and Retirement Longitudinal Study, and Indonesia Family Life Survey are included. Descriptive methods, logistic and multinomial regression analyses are used to examine patterns in any help received and main source of help respectively. After controlling for age, marital status, and co-residence with child(ren), it is found that men in all four countries overwhelmingly relied on their spouse for care, while children are more likely to be the main source of care for women. Children as the main source of care increased with age in each country and among men and women, surpassing spouse in China and Indonesia, and to a lesser extent in Mexico, but not in the United States where spouse was found to be more likely to be main caregiver even among the oldest age groups. Caregiving for the disabled is important for the well-being of the care recipient and for caregivers. Our results shed light on the asymmetric burden of caregiving on female spouses, across four diverse and aging countries.

A Pressure Release Valve: South Korean Long-Term Care Policy as Supplemental to Family Elder Care

South Korea's National Long-term Care Insurance (NLTCI) has received international acclaim for its universal continuum-of-care model. Based on 25 qualitative interviews with family caregivers, this research explores the relationship between NLTCI policies and experiences of family caregiving for older people. Caregivers who share care responsibilities or are supported by other family are coping well with minor to moderate policy recommendations. Lone caregivers without support from other family are struggling and express desire for expanded services. These findings highlight a need for more consideration of the influence of family dynamics on informal caregiver burdens. Despite many strengths, NLTCI policy functions as a pressure release valve, supplementing family care for seniors - not replacing it - with minimal gender equity contributions.

Developing a comprehensive model of home-based formal care for elderly adults in Iran: A study protocol

BACKGROUND

Due to the increasing Iran's aging population, designing a home care model is necessary. However, the data on designing the home care model for elderly adults among developing countries are limited. This study will be carried out to develop a formal home-based care model for elderly adults in Iran.

METHODS

This multi-method study will include three phases: First, Mixed-methods sequential explanatory study including two steps: One, survey to determine the prevalence of dependence on formal and informal caregivers among people aged ≥ 60 years living in Tabriz metropolis; and two, content analysis approach includes face-to-face, semi-structured interviews with the older adults receiving formal care at home, their caregivers and relevant key informants on the characteristics of care and caregiver, challenges and expectations of standard care. In phase 2, a scoping review will be used to find out the components of home care in other countries, such as care provider organization, caregivers training, and financing. PubMed, Scopus, Web of Science, EMBASE, Google scholar databases and grey literature will be run to retrieve relevant evidence using proper MeSH terms. In phase3, the triangulation method (using the results of the previous phases, reviewing national upstream documents and the focus group discussion) will be done to reach consensus and design the initial model for the Iranian context. In the following, a Delphi study will be conducted on the validation and feasibility of the developed model.

DISCUSSION

The current health infrastructure in Iran is focused on caring for younger people, despite the near future population aging. Most studies have addressed the challenges of geriatric care, but no study has addressed the various dimensions of home care in Iran and how to provide this service to elderly adults. Providing a comprehensive model of home care for the elderly can improve the quality of life and satisfaction of the elderly and their caregivers.

Associations between social support and poverty among older adults

BACKGROUND

With population aging becoming a pressing global concern, social support is more meaningful for older adults. In particular, financial supports, such as health insurance and financial assistance derived from family, all play great role in assistance affairs. Research shows social support possibly has an impact on poverty, but the association between formal and informal supports is unclear. We are aimed at verifying the association between distinct social supports and exploring whether this association would affect poverty alleviation for older adults.

METHODS

A total of 2,683 individuals aged 60 years or older who have medical expenses were included in a survey conducted by the China Health and Retirement Longitudinal Study in 2018. A chi-square analysis and an independent samples T test all were used to explore the differences of social supports among old people with different economic condition. A binary logistic regression was aimed at analyzing the association between social supports and poverty for older adults. The structural equation model was established to evaluate the association between formal support and informal support and the mechanism(s) of social supports affecting poverty.

RESULTS

The overall average rate of reimbursement for outpatient care was 0.20 with standard deviation 0.22, and the average reimbursement rate of inpatient care for the poor older adults is nearly 5% lower than the average of the non-poor older adults. We found that having private health insurance and higher reimbursement rate of inpatient care were associated with lower likelihood of living in poverty for older adults. Formal support would directly affect poverty, but its impact on poverty through informal support is insignificant even if formal support is negatively associated with informal support.

CONCLUSION

A dilemma in reducing the economic burden of disease and receiving family assistance for older adults was revealed, and a more complete health security and higher level of medical expenses compensation would be beneficial to prevent poverty. Optimizing the primary healthcare and increasing the percentage of insurance compensation, policies that focus on the specific cultural values and strengthening the role of supplementary insurance are advantaged for alleviating poverty among older adults.

The care types choice in filial culture: A cross-sectional study of disabled elderly in China

For the past few decades, studies of care types choice have been restricted to the scope of individual characteristics and health status. Meanwhile, the historiography of the research largely ignores the role of filial culture within China. This study sets out to examine the influence of the factors in the cultural context of filial piety on the choice of care types for older people with disability in China. According to the characteristics of filial culture, the factors influencing the choice of care type for the older people in China are summarized as family endowment and support. The study concludes that gender, residence, living alone or not, family income, real estate, pension and community service have momentous effects on the choice of care type of older people with disability; informal care has a substitutive effect on formal care. The research was based on cross-sectional data of CLHLS 2018 and utilized binary logistic regression analysis to compare the factors influencing the choice of old disabled people between formal and informal care. The study implies that in the context of filial culture, the older people's choice of care types is affected by family endowment and community service supply for the older people in China. In the background of filial culture, the government should give informal care official support such as cash and services, so as to change its attribute of private domain of it and enhance the quality of long-term care.

Care Task Division in Familialistic Care Regimes: A Comparative Analysis of Gender and Socio-Economic Inequalities in Austria and Slovenia

Demographic aging has led to an increase in the number of people with multiple needs requiring different types of care delivered by formal and informal carers. The distribution of care tasks between formal and informal carers has a significant impact on the well-being of carers and on how efficiently care is delivered to users. The study has two aims. The first is to explore how task division in care for older people differs between two neighboring countries with different forms of familialism: Slovenia (prescribed familialism) and Austria (supported familialism). The second is to explore how income and gender are associated with task division across these forms of familialism. Multinomial logistic regression is applied to SHARE data (wave 6, 2015) to estimate five different models of task division, based on how personal care and household help are distributed between formal and informal carers. The findings show that the task division is markedly different between Slovenia and Austria, with complementation and supplementation models more frequent in Austria. Despite generous cash benefits and higher service availability in Austria, pro-rich inequalities in the use of formal care only are pervasive here, unlike in Slovenia. Both countries show evidence of pro-poor inequalities in the use of informal care only, while these inequalities are mostly absent from mixed models of task division. Generous cash transfers do not appear to reduce gender inequalities in supported familialism. Supported familialism may not fundamentally improve inequalities when compared with less generous forms of familialism.

A Qualitative Study on the Position and Role of Volunteers in Integrated Care-An Example of Palliative Care in Croatia

Volunteers have been present in palliative care since its inception. With the development of palliative care systems, their role and position are changing. Given growing long-term care needs and limited resources in health and social care, volunteers are becoming an important resource in meeting these needs. In Croatia, palliative care has been developing as an integrated care model since 2014. To assess the position and the role of volunteers, we analyzed legislative documents from healthcare and social care and conducted a focus group with volunteers in palliative care. We found that volunteers provide support from the social aspect of care, for the patient and the family. The formal palliative care system involves them as partners in the provision of care, even though this cooperation is informal. The main determinants of their activities are an individualized approach, flexibility, a community presence, and project funding. In conclusion, these determinants allow them to react quickly to identified needs, but with them come some uncertainties of their sustainability. Their activities could indicate what needs to be integrated between health and social care and in what areas. Volunteers both fill in gaps in the system and are ahead of the system, and by doing this they develop new processes around identified unmet needs.

Social support and loneliness among frail older adults attending daycare centers: A multicultural study in Israel

AIMS

To examine the link between intensity of use of formal support and loneliness among older adults, controlling for family support and covariates; and examine the moderating effect of contact frequency with family on this relationship.

METHODS

Cross-sectional data were collected from September 2016 - April 2017 through structured interviews with 360 older adults attending adult day care centers (ADCCs) and representing three different ethnic groups in Israel. Loneliness was assessed by the UCLA Loneliness Scale. Hierarchical regression was applied to the study variables with loneliness scores as dependent variable, and bootstrapping with resampling strategies tested a moderating effect.

RESULTS

Loneliness was linked negatively with contact frequency with the family network, frequency of ADCC attendance, and greater involvement in social activities at the ADCC. Significant negative correlation between ADCC attendance frequency and loneliness occurred only when family contact was at low-to-average frequency, but not in cases of high-contact frequency.

CONCLUSIONS

Frequent use of ADCCs emerged as a significant contributor beyond the contribution of family support for reducing loneliness in older age, particularly for those with insufficient family contact. Service providers should improve the accessibility and availability of formal community services for the older population.

Long-Term Care Market Trend and Patterns of Caregiving in the U.S

Informal care is a major source of long-term services and supports (LTSS) for older adults in the U.S. However, the increasing gap between available family caregivers and those needing LTSS in coming years warrants better understanding of the balance between informal and formal home or community-based LTSS to meet the growing demand. The current study aimed to 1) identify patterns of informal and formal LTSS use among community-dwelling individuals, and 2) examine if the supply of formal LTSS predicts the use of informal care. These aims were investigated by linking the market supply of formal LTSS at the state-level to the Health and Retirement Survey data (N = 7,781). Results provide important empirical evidence that patterns of informal and formal LTSS use among older adults are heterogeneous and market supply of formal home and community-based services (HCBS) significantly predicts the use of informal care. Most older adults rely on informal care in combination with some formal supports, suggesting that the two systems work in tandem to meet the growing needs of LTSS. This offers important implications for states allocating resources to meet the LTSS needs of older adults and individuals with disabilities since states play key roles in U.S. long-term care policies.

The determinants of the intensity of home-based informal care among cancer patients in receipt of home-based palliative care

BACKGROUND

Understanding the determinants of the intensity of informal care may assist policy makers in the identification of supports for informal caregivers. Little is known about the utilization of informal care throughout the palliative care trajectory.

AIM

The purpose of this study was to analyze the intensity and determinants of the use of informal care among cancer patients over the palliative care trajectory.

DESIGN

This was a longitudinal, prospective cohort design conducted in Canada. Regression analysis using instrumental variables was applied.

SETTING/PARTICIPANTS

From November 2013 to August 2017, a total of 273 caregivers of cancer patients were interviewed biweekly over the course of the care recipient's palliative care trajectory. The outcome was the number of hours of informal care provided by unpaid caregivers, that is, hours of informal care.

RESULTS

The number of hours of informal care increased as patients approached death. Home-based nursing care complemented, and hence, increased the provision of informal care. Patients living alone and caregivers who were employed were associated with the provision of fewer hours of informal care. Spousal caregivers provided more hours of informal care. Patient's age, sex, and marital status, and caregiver's age, sex, marital status, and education were associated with the number of hours of informal care.

CONCLUSIONS

The intensity of informal care was determined by predisposing, enabling, and needs-based factors. This study provides a reference for the planning and targeting of supports for the provision of informal care.

'The Devil's Company': A Grounded Theory Study on Aging, Loneliness and Social Change Among 'Older Adult Children' in Rural Indonesia

Introduction: As a consequence of rising life expectancies, many families are no longer made up of one, but two simultaneously aging generations. This elderly parent-older adult child (OAC) dyad has emerged as a newly overserved yet little explored demographic phenomenon. Studies on this intergenerational aging dyad and the possible ramifications of when caregivers are simultaneously aging with care-receivers are scarce, especially in low and middle-income countries. This study explored the process by which rural Indonesian OACs experience their own aging, thereby gaining insights into how this newly evolving reality impacts the traditional ways of old-age care provision. Methods: This study has a qualitative design and draws on eight focus group discussions with 48 community-dwelling OACs (23 men, 25 women; mean age 64 years) in four rural villages in the Yogyakarta Special Region, Indonesia. The theoretical framework was largely inspired by symbolic interactionism aided by the sensitizing concepts of social network deficits, interpersonal emotions, and the social construction of risks. Data were analyzed using Grounded Theory as outlined by Corbin and Strauss. Results: Respondents' accounts reflected four categories: 1) aging in a welt of chronic insecurity; 2) OACs: a generation "betwixt and between" expected demands and unmet expectations; 3) landscapes of loneliness; and 4) compromising against conventions. As depicted in a conceptual model, these categories interrelated with each other and were linked by a core category, "bargaining for a sense of security", which collectively summarized a process by which OACs' experienced their own course of aging. Conclusion: Our study provided insights into how and why loneliness emerged amidst the challenges of social and demographic transformations and how in response to this unconventional compromises were made, which affect both the networks of caretakers and the places of old-age care. It is doing so by including the perspectives of rural Indonesian OACs. The results showed how multiple intersecting negative experiences constrained the aging experiences of OACs and produced precarious aging trajectories. Our findings highlight the importance of old-age loneliness as an emerging public health and social problem by discussing how intrinsically this emotion was interwoven with social life.

The direct cost of disability of community-dwelling older persons in Belgium

Current policies aim to promote and develop community-based support of disabled elderly persons, yet knowledge of the cost implications is insufficient. Thus, we aimed to estimate, for three disability profiles and three presence levels of the main informal carer (none, non-cohabitant, cohabitant), the cost of formal and informal support currently provided at home in Belgium. In this cross-sectional study, a sample of 5,642 disabled elderly persons living at home was established between 2010 and 2016. The administrative database of the Belgian public healthcare insurance was merged with other prospective data on social care service utilisation, informal care and disability. The total cost of formal support ranged from €725 to €1,344 (on average, per person, per month), depending on the three disability profiles identified. Twenty-five per cent of persons with the highest level of disability (important functional limitations and cognitive impairment) and helped by a cohabitant carer, had a low total cost of formal support: below €382 per month. Informal care represented the main cost component of total support costs in the three disability profiles (between 64 and 76%). To prevent the worsening of situations of disabled older persons and their informal carers, better detection of seriously disabled persons with low levels of formal support is crucial.

Professional Care Networks of Frail Older People: An Explorative Survey Study from the Patient Perspective

BACKGROUND

Frail older people living in the community require multidisciplinary care. Despite the fact that patient participation is high on the public agenda, studies into multidisciplinary care mainly focus on the viewpoints of professionals. Little is known about frail older patients' experiences with care delivered by multidisciplinary teams and their perception of collaboration between professional and informal caregivers.

OBJECTIVE

To gain more insight into the experiences of frail older patients with integrated multidisciplinary care by mapping the care networks of this patient group and their perception of the interconnection between professional and informal caregivers.

METHODS

Survey study to facilitate a care network analysis. Due to the vulnerable health status of the respondents, questionnaires were completed during interviews. Analysis was performed using an iterative process, using both visual and metric techniques.

PARTICIPANTS

44 older persons, considered 'frail' by their general practitioner.

SETTING

Four general practices in The Netherlands.

RESULTS

The networks of the participants consisted of an average of 15 actors connected by 54 ties. General practitioners were the most common actors in the networks, and were well connected to medical specialists and in-home care providers. The participants did not always perceive a connection between their general practitioner and their informal caregiver. The network analyses resulted in the identification of three subtypes: simple star (n = 16), complex star (n = 16), and sub-group networks (n = 12).

CONCLUSIONS

Our findings indicate that the elderly often do not experience the integration of multidisciplinary care as such. This is a real opportunity for MTs to improve their care and to make the patients' experiences better in line with what they are aiming: allowing patients to live at home as healthy and independently as possible for as long as possible. We showed that informal caregivers often form communication bridges between patients and professionals. Having a better knowledge of the patient perspective enables the gaps in professional care networks of frail older people to be filled and facilitates the anticipation of crisis situations.

Whose responsibility? Elder support norms regarding the provision and financing of assistance with daily activities across economically developed countries

We use 2012 data on economically developed countries from the International Social Survey Program to examine variation in “cultural norms” (at the world region and country levels) and “attitudes” (at the individual level) regarding the appropriate roles of family members and formal providers in both the provision and financing of assistance with daily activities at home. Our analysis has two parts: (1) a descriptive analysis of differences in cultural norms by world region and country (N = 25 countries) and (2) a multilevel multinomial logistic regression analysis of the importance of country-level factors in explaining individuals’ elder support attitudes (N = 21 countries). In the descriptive analysis, we find substantial variation in cultural norms both between world regions and between countries within all world regions except for the Nordic countries. The multilevel regression analysis points to the importance of two sets of country-level factors—“macrostructural factors” and “cultural–contextual factors”—in explaining individuals’ elder support attitudes. With regard to macrostructural factors, we find, consistent with our hypotheses, greater support for “publicly financed formal assistance” (i.e., the financing of formal assistance is supported by public funds) in countries with higher spending on services. The effects of the cultural–contextual factors are mostly consistent with our hypotheses and suggest the importance of taking into account the wider religious and political context in explaining individuals’ elder support attitudes. We conclude with a discussion of the social scientific and social policy implications of our findings.

Do caregiver profiles predict the use of dementia care services? Findings from the Actifcare study

Objectives: Previously developed dementia caregiver profiles defined by caregiver age and burden, have been associated with caregiver quality of life, depression and perseverance time. The current aim was to investigate whether these caregiver profiles could predict subsequent service use. In addition, non-personal (e.g. meals on wheels) and supportive services (e.g. Alzheimer café) in early dementia were investigated as predictors.Methods: A total of 451 dyads of people with dementia and their informal caregivers from eight European countries were followed for one year. People were included if they did not use formal (personal) care but were expected to do so within 1 year. Logistic regression analyses were used with four clusters of service use as dependent variables (home social care, home personal care, day care and admission). The independent variables were caregiver profiles, and non-personal and supportive services at baseline.Results: Caregiver profiles were significant predictors of service use; those experiencing high strain were more likely to use formal care. The use of low-intensity, less intrusive services at baseline significantly predicted the use of home personal care and admission at follow-up. The use of day care at follow-up was predicted by the baseline use of supportive services.Conclusion: Caregiver profiles are valuable predictors for service use: this knowledge can aid professionals in ensuring optimal access to services, which is important for maintaining independence at home. In addition, the use of supportive and less intrusive, non-personal services in the early stages of dementia is to be advised.

Is informal care sufficient to meet the long-term care needs of older people with disabilities in China? Evidence from the China Health and Retirement Longitudinal Survey

Rapid demographic shifts and socio-economic changes are fuelling concerns over the inadequate supply of informal care – the most common source of care-giving for older people in China. Unmet long-term care needs, which are believed to cause numerous adverse effects on health, continue to increase. Drawing data from the 2015 wave of the China Health and Retirement Longitudinal Survey, this study explores the relationship between informal care provision and unmet long-term care needs among older people in China. We first examine the availability of informal care among older people with disabilities. We then analyse whether a higher intensity of informal care leads to lower unmet needs. Our findings suggest that the majority of older people with disabilities receive a low intensity of care, i.e. less than 80 hours per month. Besides, a higher intensity of informal care received could significantly lower the probabilities of unmet needs for the disabled older adults who have mainly instrumental activities of daily living limitations. Our study points out that informal care cannot address the needs of those who are struggling with multi-dimensional difficulties in their daily living. Our findings highlight a pressing need for the government to buttress the formal care provision and delivery systems to support both informal care-givers and disabled older people in China.

The contribution of hospital-based home health services in pulmonary diseases: Current Practice in Turkey

BACKGROUND

The medical management of chronic respiratory diseases becomes more difficult with the increase in the rate of the elderly population. Monitoring and treating chronic respiratory diseases at home are more comfortable for both the patient and their relatives. Therefore, countries need to develop policies regarding home health services (HHS) according to the state of their social, cultural, and financial infrastructure.

OBJECTIVE

The objective of this study is to show the role and contribution of hospital-based HHS regarding respiratory disorders, and to evaluate the model and its efficiency.

STUDY DESIGN

The design of this study was cross-sectional. Data were obtained from the Ministry of Health of Turkey with official permission. Data were collected for HHS concerning respiratory diseases between 2011 and 2017. Age and sex distribution, the number of recorded patients, the number of visits for pulmonary diseases, the distribution of institutional visits, and the quantitative alterations within the years were investigated.

STUDY POPULATION

The study population was based on patients with respiratory disorders who were given HHS as directed by the Ministry of Health of Turkey.

RESULTS

Between 2011 and 2017, the majority of patients with pulmonary diseases, mostly those with chronic obstructive pulmonary disease, asthma, and lung cancer, visited government hospitals (78%). The number of house visits concerning pulmonary disorders increased nearly ten times, but hospitalization due to respiratory diseases decreased (13.5% in 2011 to 12.9% in 2017).

CONCLUSION

Hospital-based HHS in pulmonary diseases can be considered as an appropriate model for implementation for countries like Turkey, those that have inadequate hospice-type health service infrastructure.

Mirror meetings with frail older people and multidisciplinary primary care teams: Process and impact analysis

OBJECTIVES

To analyse the process and impact of confronting multidisciplinary teams (MTs) in primary care with the experiences of frail older patients through mirror meetings (MMs), with the aim of supporting teams to organize care in a more patient-oriented way.

METHODS

Process and impact analyses were performed using a mixed-method approach. MMs were held with 14 frail older patients and four MTs comprising 23 health-care professionals (HCPs) in primary care in the Netherlands.

RESULTS

Mirror meetings were feasible for frail older people living at home, although their recruitment was time-consuming. Interaction between the patients was scarce, but they valued the opportunity to share their stories. HCPs preferred MMs overwritten reports about patient experiences. An impact analysis revealed four dominant professional areas for improvement: improve alignment with patient goals, improved communication with patients both orally and in writing, developing new pathways to connect with informal caregivers and an increased understanding that most HCPs are relative strangers to their patients.

CONCLUSIONS

Mirror meetings are a relatively simple and promising method for exploring the ways in which frail older patients experience care.

PRACTICE IMPLICATIONS

Given the right conditions, MMs could result in valuable processes to enable MTs to improve their working methods.

Caregiving for Community-Dwelling Older Persons in South Korea: Current Formal and Informal Care Use and Expectation

The aim of this study is to examine formal and informal care use among community-dwelling older Korean adults. Older adults aged between 65 and 85 ( N = 516) in mid-size city, selected using the probability proportional sampling method, were interviewed in person. One third reported having at least one caregiver. Compared to respondents who did not use any informal/formal care, those who used any formal or informal care were older and were more likely to be prefrail or frail and experienced at least one hospitalization or emergency department use in the past year. Living alone or being experienced with any hospitalization was associated with formal care use. Most care recipients received informal care from families, specifically spouses. Among participants who received no formal/informal care, 19% of them expected to receive formal care support in the future. Substantial support programs for informal caregivers are needed to address the increase in demand and expectation for long-term care.

The role of social networks in using home care by older people across Continental Europe

The diversification of caregiving arrangements in European societies has drawn attention to the factors that condition the use of care by older people. Social and family relations appear as a key factor, mainly to be related to the availability and accessibility to potential informal caregivers. Recent studies evidenced that geographical proximity and a larger social network increase the probability of receiving informal support in old age. However, the ways in which interpersonal relationships are associated with the use of formal care, as well as the cross-country variability of this association, have been barely explored. Using a sample of 37,708 individuals aged 65 and over from Wave 6 of the Survey of Health, Ageing and Retirement in Europe (SHARE), this study examines to what extent the characteristics of older people's social networks predict the use of three types of home care; formal, informal, or combined, exploring the cross-European convergences and divergences. Binomial logistic regressions are conducted to compare four macro-regions in continental Europe (northern countries: Denmark and Sweden; western countries: Austria, Belgium, France, Germany, Switzerland, and Luxembourg; southern countries: Italy, Spain, Greece, and Portugal; and eastern countries: Poland, Czech Republic, Slovenia, Estonia, and Croatia). The structure, availability, and accessibility to the members of the social network are the major predictors of the receipt of informal care everywhere. Regional divergences are observed regarding to formal care, alone or combined with informal caregivers.

Evaluation of bottom-up interventions targeting community-dwelling frail older people in Belgium: methodological challenges and lessons for future comparative effectiveness studies

Background

Optimizing the organization of care for community-dwelling frail older people is an important issue in many Western countries. In Belgium, a series of complex, innovative, bottom-up interventions was recently designed and implemented to help frail older people live at home longer. As the effectiveness of these interventions may vary between different population groups according to their long-term care needs, they must be evaluated by comparison with a control group that has similar needs.

Methods

The goal was to identify target groups for these interventions and to establish control groups with similar needs and to explore, per group, the extent to which the utilization of long-term care is matched to needs. We merged two databases: a clinical prospective database and the routine administrative database for healthcare reimbursements. Through Principal Component Analysis followed by Clustering, the intervention group was first stratified into disability profiles. Per profile, comparable control groups for clinical variables were established, based on propensity scores. Using chi-squared tests and logistic regression analysis, long-term care utilization at baseline was then compared per profile and group studied.

Results

Stratification highlighted five disability profiles: people with low-level limitations; people with limitations in instrumental activities of daily life and low-level of cognitive impairment; people with functional limitations; people with functional and cognitive impairments; and people with functional, cognitive, and behavioral problems. These profiles made it possible to identify long-term care needs. For instance, at baseline, those who needed more assistance with hygiene tasks also received more personal nursing care (P < 0.05). However, there were some important discrepancies between the need for long-term care and its utilization: while 21% of patients who were totally dependent for hygiene tasks received no personal nursing care, personal nursing care was received by 33% of patients who could perform hygiene tasks.

Conclusions

The disability profiles provide information on long-term care needs but not on the extent to which those needs are met. To assess the effectiveness of interventions, controls at baseline should have similar disability profiles and comparable long-term care utilization. To allow for large comparative effectiveness studies, these dimensions should ideally be available in routine databases.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4240-9) contains supplementary material, which is available to authorized users.

Innovating Long-Term Care Provision in Mediterranean Welfare States: A Comparison Between Italy and Israel

Social innovations in long-term care (LTC) may be useful in more effective responses to the challenges of population aging for Western societies. One of the most investigated aspects in this regard is the role of family/informal care and strategies to improve its integration into the formal care system, yielding a more holistic care approach that may enhance opportunities for aging in place. This article reports the findings of a comparative research focusing on the Italian and Israeli LTC systems as representative of the Mediterranean "family-based" care model. To analyze the innovative solutions that have been adopted or are needed to improve LTC provision in these two contexts, focus groups and expert interviews have been carried out in both countries to identify the most relevant challenges and responses to them and to highlight promising policies and strategies to be adopted or up-scaled in the future. These include multidisciplinary case and care management, a stronger connection between prevention and LTC provision, and more systematic recognition of the role and limits of informal caregivers' contributions.

Does informal care impact utilisation of home-based formal care services among end-of-life patients? A decade of evidence from Ontario, Canada

Understanding how informal care impacts formal care utilisation for home-based end-of-life patients is an important policy- and practice-relevant question. This paper aims to assess the relationship between informal and formal home care among home-based end-of-life patients and how this relationship has changed over the last decade and over the end-of-life trajectory. We focus on informal care provided by family members or friends, and three types of home-based formal care services: care by personal support workers, physician visits, and nurse visits. Using survey data collected in a home-based end-of-life care programme in Ontario, Canada from 2005 to 2016, we build a two-part utilisation model analysing both the propensity to use each type of formal care and the amount of formal care received by patients. The results suggest that informal care is a substitute for care by personal support workers, but a complement to physician visits and nurse visits. In the case of nurse visits, an increased complementary effect is observed in more recent years. For home-based physician and nurse visits, the complementary effect grows with patient's proximity to death. These results highlight the complexity of the relationship between informal and formal care among home-based end-of-life patients. Decision-makers need to take into account the relationship between informal care and different types of formal services when introducing future policies.

Frailty differences in older adults' use of informal and formal care

OBJECTIVES

This study examines different combinations of informal and formal care use of older adults and investigates whether these combinations differ in terms of need for care (physical and psychological frailty) and enabling factors for informal and formal care use (social and environmental frailty).

METHODS

Using cross-sectional data from the Belgian Ageing Studies (survey, N = 38,066 community-dwelling older adults), Latent Class Analysis (LCA) is used to identify combinations of informal and formal care use. Bivariate analyses are used to explore the relationship between the different combinations of care use and frailty.

RESULTS

Latent Class Analysis (LCA) identified 8 different types of care use, which vary in combinations of informal and formal caregivers. Older adults who are more likely to combine care from family and care from all types of formal caregivers are more physically, psychologically and environmentally frail than expected. Older adults who are more likely to receive care only from nuclear family, or only from formal caregivers are more socially frail than expected.

CONCLUSIONS

Older adults with a higher need for care are more likely to receive care from different types of informal and formal caregivers. High environmental frailty and low social frailty are related with the use of care from different types of informal and formal caregivers. This study confirms that informal care can act as substitute for formal care. However, this substitute relationship becomes a complementary relationship in frail older adults. Policymakers should take into account that frailty in older adults affects the use of informal and formal care.

Formal and informal care for community-dwelling frail elderly people over time: A comparison of integrated and usual care in the Netherlands

While integration has become a central tenet of community-based care for frail elderly people, little is known about its impact on formal and informal care and their dynamics over time. The aim of this study was therefore to examine how an integrated care intervention for community-dwelling frail elderly people affects the amount and type of formal and informal care over 12 months as compared to usual care. A quasi-experimental design with a control group was used. Data regarding formal and informal care were collected from frail elderly patients (n = 207) and informal caregivers (n = 74) with pre/post-questionnaires. Within- and between-group comparisons and multiple linear regression analyses were performed. The results showed marginal changes over time in the amount of formal and informal care in both integrated care and usual care. However, different associations between changes in formal and informal care were found in integrated and usual care. Most notably, informal caregivers provided more instrumental assistance over time if formal caregivers provided less personal care (and vice versa) in integrated care but not in usual care. These results suggest that integrated care does not necessarily change the contribution of formal or informal care, but changes the interaction between formal (personal care) and informal (instrumental) activities. Implications and recommendations for research and practice are discussed.

TRIAL REGISTRATION

Current Controlled Trials ISRNT05748494.

Utilization of Formal and Informal Home Care: How Do Older Canadians’ Experiences Vary by Care Arrangements?

This study investigates how the receipt of formal, informal, and/or a combination of both types of care at home relates to older adults’ perceived loneliness, life satisfaction, and day-to-day lives. Quantitative analyses using the Canadian Community Health Survey ( n = 3,928) reveal that older adults who only received formal care reported lower levels of loneliness and higher levels of life satisfaction when compared with respondents who received informal or a blend of home care. Qualitative analyses of persons aged 65+ years receiving formal and informal home care in Ontario ( n = 34) suggest that formal care bolstered care recipients’ autonomy and reduced their sense of being a burden on family. In turn, receiving formal care served to improve these older adults’ social connectedness and well-being. Findings underscore older adults’ symbolic, functional, and emotional attachment to formal care services, as well as the limitations of a reliance on informal support.

Cohort Differences in Received Social Support in Later Life: The Role of Network Type

Objectives

The objective is to assess cohort differences in received emotional and instrumental support in relation to network types. The main guiding hypothesis is that due to increased salience of non-kin with recent social change, those in friend-focused and diverse network types receive more support in later birth cohorts than earlier birth cohorts.

Method

Data from the Longitudinal Aging Study Amsterdam are employed. We investigate cohort differences in total received emotional and instrumental support in a series of linear regression models comparing birth cohorts aged 55-64, 65-74, 75-84, and 85-94 across three time periods (1992, 2002, and 2012).

Results

Four network types (friend, family, restricted, and diverse) are identified. Friend-focused networks are more common in later birth cohorts, restrictive networks less common. Those in friend-focused networks in later cohorts report receiving more emotional and instrumental support. No differences in received support are evident upon diverse networks.

Discussion

The increased salience of non-kin is reflected in an increase in received emotional and instrumental support in friend-focused networks in later birth cohorts. The preponderance of non-kin in networks should not be perceived as a deficit model for social relationships as restrictive networks are declining across birth cohorts.

Determinants of formal care use and expenses among in-home elderly in Jing'an district, Shanghai, China

The need for formal care among the elderly population has been increasing due to their greater longevity and the evolution of family structure. We examined the determinants of the use and expenses of formal care among in-home elderly adults in Shanghai. A two-part model based on the data from the Shanghai Long-Term Care Needs Assessment Questionnaire was applied. A total of 8428 participants responded in 2014 and 7100 were followed up in 2015. The determinants of the probability of using formal care were analyzed in the first part of the model and the determinants of formal care expenses were analyzed in the second part. Demographic indicators, living arrangements, physical health status, and care type in 2014 were selected as independent variables. We found that individuals of older age; women; those with higher Activities of Daily Living (ADL) scores; those without spouse; those with higher income; those suffering from stroke, dementia, lower limb fracture, or advanced tumor; and those with previous experience of formal and informal care were more likely to receive formal care in 2015. Furthermore, age, income and formal care fee in 2014 were significant predictors of formal care expenses in 2015. Taken together, the results showed that formal care provision in Shanghai was not determined by ADL scores, but was instead more related to income. This implied an inappropriate distribution of formal care among elderly population in Shanghai. Additionally, it appeared difficult for the elderly to quit the formal care once they begun to use it. These results highlighted the importance of assessing the need for formal care, and suggested that the government offer guidance on formal care use for the elderly.

The association of mobility limitation and social networks in relation to late-life activity

The current study examines the interaction between mobility limitations and social networks in relation to activity in later life. Although the importance of activity participation to successful ageing has been well established, it is still unclear what contributes to higher levels of activity. This research addresses this issue, using data from the Survey of Health, Ageing and Retirement in Europe. The analysis focuses on a sub-sample of respondents aged 60 and older, from 13 countries, who participated in two specific waves, in 2011 and 2013. Multivariate analysis of the longitudinal data was conducted using hierarchical generalised Poisson regression and incorporating a new comprehensive social network scale. The inquiry found that having multiple mobility limitations is associated with less activity and that having a resourceful social network contributes to more activity. The research further revealed that social network is particularly beneficial to those with multiple mobility limitations because it mitigates the negative association with activity. This conclusion furthers the understanding of the relationship between different key dimensions in the successful ageing paradigm. Specifically, the findings imply the significance of having a social network among those who are functionally challenged. This finding has important implications for active ageing policies.

Support networks of childless older people: informal and formal support in Europe

Western societies are ageing rapidly. Today people do not only live longer, they also have fewer children. These developments exert considerable pressure on welfare states. Children have usually been the mainstay of old age support, especially when there is no partner. We thus face new challenges: On which support networks can a growing number of childless older people rely? (How) can the lack of children be compensated in the informal social network? What role does the state play and how is informal and formal support linked? Our comparative analyses of the support networks of childless elders are based on the first two waves of the Survey of Health, Ageing and Retirement in Europe, including 14,394 people with (instrumental) activities of daily living limitations aged 50 and over from 12 European countries. On average, 10 per cent of older Europeans today have no children. Sporadic informal support for these elders is often taken over by the extended family, friends and neighbours, and thus the lack of children is compensated within the social network. Intense care tasks, however, are more likely provided by professional providers, especially in the case of childless older people. In countries with low social service provision, childless elders are therefore likely to experience a lack of (formal) support, especially when depending on vital care.

Trends in the informal and formal home-care use of older adults in the Netherlands between 1992 and 2012

This study investigates trends in, and the interdependence of, the use of informal and formal home care of community-dwelling older people over the last two decades in the context of governmental reform of long-term care services and modernisation of informal relationships. Seven observations of the Longitudinal Aging Study Amsterdam covering the time span between 1992 and 2012 were analysed using multi-level logistic regression analysis. The sample entailed 9,585 observations from 3,574 respondents, aged between 65 and 85 years and living independently at each time of measurement. Measures included formal and informal care use, health, physical and cognitive limitations, socio-demographics, partner status, social network, privately paid help and sense of mastery. Results showed that between 1992 and 2012, formal home-care use increased slightly while there was a large decrease in the use of informal care. Multivariate multi-level logistic regression analyses showed a substitution effect between formal and informal care use which decreased over time. Analyses also showed improved cognitive functioning, increased partner availability and social network size, as well as increased use of privately paid care over time. Nevertheless, these positive trends did not explain the large decrease in informal care use. The results regarding informal care use suggest a societal trend of weakened informal solidarity, reflecting increased individualisation and increased availability of formal home care. The decreased substitution effect suggests that, in agreement with current reforms of long-term care, complementary or supplementary forms of care use may be more common in the near future.

A triadic perspective on elder neglect within the home care arrangement

The present study evaluates a conceptual model of elder neglect within the home care arrangement that takes into consideration the older adult, his or her family members, and the home care worker. Data from 223 complete care-giving units, which consist of an older adult, a family member and a home care worker, were analysed using structural equation modelling. Overall, 31.5 per cent of the older adults, 18 per cent of the care workers and 32.3 per cent of the family members reported at least one type of elder neglect. The proposed model showed a reasonable fit to the data. There was an inverse effect from type of home care to family member's burden and elder neglect, with live-in (around the clock) care being associated with lower levels of family member burden and elder neglect compared with live-out Israeli home care (provided for several hours per week). The amount of informal assistance provided by family members was inversely related to the amount of burden reported by home care workers, with greater informal assistance being associated with lower levels of worker burden. The findings call for the important role of formal home care by demonstrating a potentially protective effect for live-in migrant home care. The study also emphasises the shared burden between formal and informal sources of care.

Who cares? A comparison of informal and formal care provision in Spain, England and the USA

This paper investigates the prevalence of incapacity in performing daily activities and the associations between household composition and availability of family members and receipt of care among older adults with functioning problems in Spain, England and the United States of America (USA). We examine how living arrangements, marital status, child availability, limitations in functioning ability, age and gender affect the probability of receiving formal care and informal care from household members and from others in three countries with different family structures, living arrangements and policies supporting care of the incapacitated. Data sources include the 2006 Survey of Health, Ageing and Retirement in Europe for Spain, the third wave of the English Longitudinal Study of Ageing (2006), and the eighth wave of the USA Health and Retirement Study (2006). Logistic and multinomial logistic regressions are used to estimate the probability of receiving care and the sources of care among persons age 50 and older. The percentage of people with functional limitations receiving care is higher in Spain. More care comes from outside the household in the USA and England than in Spain. The use of formal care among the incapacitated is lowest in the USA and highest in Spain.

Individual determinants of task division in older adults' mixed care networks

Older adults in need of long-term care often receive help from both informal and formal caregivers. The division of tasks between these different types of caregivers may vary among such mixed care networks. Traditional models of task division suggest that formal and informal caregivers may either supplement each other or specialise in the care activities performed. Our study explores the determinants of various forms of task division in the Netherlands, using data collected in 2007 on 458 mixed care situations. Four types of task divisions of informal and formal care are distinguished: the complementation model [neither Activities of Daily Living (ADL) nor instrumental ADL (IADL) tasks shared, 14%], the supplementation model (both ADL and IADL tasks shared, 39%) and informal and formal specialisation (one type of task shared, one type of task not shared, 27% and 20% respectively). Marginal effects calculated with multinomial regression analyses show that the intensity of care provision, the informal caregivers' motives and the presence of privately paid help - more than care receiver's health - are related to type of task division with formal care. For example, when the informal caregiver provides more hours of help and out of a strong personal bond, the likelihood of informal specialisation increases, whereas the likelihood of formal specialisation decreases. When privately paid help is present, the complementation model is more likely, whereas the supplementation model is less likely to be found. Results are discussed regarding the differential consequences for co-ordination and co-operation in mixed care networks.

Associations Between Secondary Caregivers' Supportive Behavior and Psychological Distress of Primary Spousal Caregivers of Cognitively Intact and Impaired Elders

PURPOSE OF THE STUDY

This study examined associations between the availability and types of supportive behavior provided by secondary caregivers and the psychological distress of primary spousal caregivers of cognitively intact and impaired elders.

DESIGN AND METHODS

A sample of 8,087 assessments using the validated Chinese version of the Minimum Data Set-Home Care of individuals applying for government-subsidized long-term care services from 2006 to 2009 in Hong Kong were selected based on inclusion criteria.

RESULTS

More than 70% of primary caregivers had secondary caregivers; the rate was slightly lower for those caring for moderately or severely cognitively impaired spouses. More than half of the primary spousal caregivers had secondary caregivers who provided both emotional and instrumental support. Emotional support provided by secondary caregivers had a negative association with primary caregivers' psychological distress when their care recipients were cognitively intact. When secondary caregivers provided both instrumental and emotional support, primary caregivers had a higher likelihood of psychological distress when care recipients had greater negative mood symptoms as compared to those who had less negative mood symptoms.

IMPLICATIONS

This is the first study that examined the association between availability and types of supportive behavior provided by secondary caregivers and the psychological distress of primary spousal caregivers of cognitively intact and impaired elders. The findings suggest a need to provide services that enhance the provision of emotional support from both secondary and primary caregivers to cognitively intact elders and support primary spousal caregivers to seek appropriate help according to the mood of care recipients.

The experience of family care-givers and migrant paid care-givers' relief of burden: a contrasted qualitative analysis

Older people are increasingly being cared for in the community across Europe. Dependent care in Spain largely remains a private issue involving family carers and migrant women from developing countries. Qualitative research on respite care has contributed to our understanding of respite as a subjective experience. Nonetheless, how care-givers relieve the burden of care is still not fully understood. Migrant care-givers are present in family life but their need for rest remains unseen. The aim of the study presented in this paper was to contrast family care-givers and migrant care-givers' strategies for relief from their caring role. Care-givers rest by thinking, doing and being but in a different manner from that of care-giving, that is: when they are a different person.To leave the life of care-givingis the general strategy that family care-givers use to rest from their care-giving selves whileturning to one's own worlddescribes the way migrant care-givers seek to relieve the burden of care. The comparative analysis shows that both strategies have in common the necessity to disconnect from the care-giving identity and that both migrant and family care-givers employ strategies that arefalse exits to a care-giving identity: they apparently relieve the burden of care. Respite goes beyond places, times and activities; as family care itself, it requires identity.

Convoys of care: theorizing intersections of formal and informal care

Although most care to frail elders is provided informally, much of this care is paired with formal care services. Yet, common approaches to conceptualizing the formal-informal intersection often are static, do not consider self-care, and typically do not account for multi-level influences. In response, we introduce the "convoy of care" model as an alternative way to conceptualize the intersection and to theorize connections between care convoy properties and caregiver and recipient outcomes. The model draws on Kahn and Antonucci's (1980) convoy model of social relations, expanding it to include both formal and informal care providers and also incorporates theoretical and conceptual threads from life course, feminist gerontology, social ecology, and symbolic interactionist perspectives. This article synthesizes theoretical and empirical knowledge and demonstrates the convoy of care model in an increasingly popular long-term care setting, assisted living. We conceptualize care convoys as dynamic, evolving, person- and family-specific, and influenced by a host of multi-level factors. Care convoys have implications for older adults' quality of care and ability to age in place, for job satisfaction and retention among formal caregivers, and for informal caregiver burden. The model moves beyond existing conceptual work to provide a comprehensive, multi-level, multi-factor framework that can be used to inform future research, including research in other care settings, and to spark further theoretical development.

The trade-off between formal and informal care in Spain

Understanding the factors that determine the type and amount of formal care is important for predicting use in the future and developing long-term policy. In this context, we jointly analyze the provision of care at both the extensive (choice of care) and the intensive margin (number of hours of care received). In particular, we estimate and test, for the first time in this area of research, a sample selection model with the particularities that the first step is a multinomial logit model and the hours of care is an interval variable. Our results support the complementary and task-specific models which evidence has been found in other countries. Furthermore, we obtain evidence of substitution between formal and informal care for the male, young, married and unmarried subsamples. Regarding the hours of care, we find significant biases in predicted hours of care when sample selection is not taken into account. For the whole sample, the average bias is 2.77% for total hours and 3.23% for formal care hours. However, biases can be much larger (up to 10-15%), depending on the subsample and the type of care considered.

The relationship between formal and informal care among adult Medicaid Personal Care Services recipients

OBJECTIVES

To test hypotheses concerning the relationship between formal and informal care and to estimate the impact of hours of formal care authorized for Medicaid Personal Care Services (PCS) on the utilization of informal care.

DATA SOURCES/STUDY SETTING

Data included home care use and adult Medicaid beneficiary characteristics from assessments of PCS need in four Medicaid administrative areas in Texas.

STUDY DESIGN

Cross-sectional design using ordinary least-squares (OLS) and instrumental variable (IV) methods.

DATA COLLECTION/EXTRACTION METHODS

The study database consisted of assessment data on 471 adults receiving Medicaid PCS from 2004 to 2006.

PRINCIPAL FINDINGS

Both OLS and IV estimates of the impact of formal care on informal care indicated no statistically significant relationship. The impact of formal care authorized on informal care utilization was less important than the influence of beneficiary need and caregiver availability. Living with a potential informal caregiver dramatically increased the hours of informal care utilized by Medicaid PCS beneficiaries.

CONCLUSIONS

More formal home care hours were not associated with fewer informal home care hours. These results imply that policies that decrease the availability of formal home care for Medicaid PCS beneficiaries will not be offset by an increase in the provision of informal care and may result in unmet care needs.

Transitions in formal and informal care utilisation amongst older Europeans: the impact of national contexts

The objective of this study was to explore how long-term care systems, and in particular the incorporation of needs-based entitlements to care services or benefits, influence formal and informal care utilisation dynamics. We used the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 1 and 2 data, restricting the sample to persons 65+ from 9 European countries (N = 6,293). The effects of changes in health and household composition on formal and informal care transitions were estimated using logistic regression, allowing these effects to vary across countries. The results indicated that, in all countries, formal and informal care were more often complements than substitutes. The likelihood of becoming a formal or informal care user varied significantly between countries. In the Scandinavian countries and in several continental European countries with needs-based entitlements, the transition to formal care was strongly related to informal support being or becoming unavailable. We found little evidence of country differences in the effect of health variables on the transition to formal care. The analysis suggested that, whilst rates of formal care utilisation continue to differ considerably between European countries, formal care allocation practices are not very dissimilar across Northern and continental European welfare states, as we found evidence for all countries of targeting of older persons living alone and of the most care-dependent older people.