Managed care and multilevel long-term care providers: reluctant partners

Bariatric Programs in Nursing Homes

The increase in prevalence of obesity in older individuals and the association of obesity with increased morbidity, functional decline, hospitalization, and complications is expected to increase the number of individuals who have obesity requiring nursing home care, particularly subacute and short-term rehabilitation. Providing appropriate nursing home care to residents who have obesity requires environmental modifications, specialized equipment, and staff training. Effective nursing home care of residents who have obesity is interdisciplinary and requires special nursing, medical, nutritional, psychosocial, and rehabilitation considerations.

Bringing managed care home to people with chronic, disabling conditions: prospects and challenges for policy, practice, and research

This article examines the challenges and opportunities inherent in the idea that home care organizations may be able to reinvent themselves into managed care systems for the frail elderly and chronically ill. Data come from three sources: (a) existing literature, (b) a survey with experts, and (c) insights from an organization with direct experience in designing and implementing first- and second-generation managed care programs. The authors conclude that although even the best-positioned home care organizations will face significant challenges in transitioning to managed care systems (e.g., establishing medical linkages, building managed care capacity, securing funding, dealing with regulatory hurdles), changes in the environment may enable these challenges to be overcome. Home care organizations are beginning to use innovative techniques to manage care, and those with a strong commitment to the chronically ill may be interested and capable of pursuing the option of becoming home-based managed chronic care programs.

Effective coordination of medical and supportive services

For at least the past quarter century, tension between "medical/allied health" and "social" models of care have characterized much of the home-care policy debate. There has also emerged a growing body of research and boundary-bending care models based on a holistic view of care recipients and caregiving. Such models coordinate between medical care and expanded supportive community services (SCS) that range from assistance with lifestyle modification, self-care, and informal care to adult-day services and home-health care. This article presents a new rationale for these models based on disablement theory and recent accounts of fairness in health policy. This approach is contrasted with the efficiency and efficacy policy perspectives that have received the most attention. The implications of an equal-opportunity approach to home-care policy for performance indicators are explored. Six basic models of coordination and current evidence on their impacts are described from this new perspective. Using qualitative data from two recent projects, five dimensions of care recipient and caregiver experiences that may be relevant to performance measurement are described. Suggestions for further service innovations and research are offered.