A Study of 10 States Since Passage of the National Family Caregiver Support Program: Policies, Perceptions, and Program Development

Racial and ethnic differences in unmet needs among older adults receiving publicly-funded home and community-based services

BACKGROUND

Unmet need for home and community-based services (HCBS) may disparately impact older adults from racial and ethnic minoritized groups. We examined racial and ethnic differences in unmet need for HCBS among consumers ≥65 years using publicly funded HCBS.

METHODS

We analyzed the National Core Indicators-Aging and Disability survey data (2015-2019) from 21,739 community-dwelling HCBS consumers aged ≥65 years in 23 participating states. Outcome measures included self-reported unmet need in six service types (i.e., personal care, homemaker/chore, delivered meals, adult day services, transportation, and caregiver support). Racial and ethnic groups included non-Hispanic Black, Asian, non-Hispanic White, Hispanic, and multiracial groups. Logistic regression models examined associations between race and ethnicity and unmet need, adjusting for sociodemographic, health, and HCBS program (i.e., Medicaid, Older Americans Act [OAA], Program for All-Inclusive Care for the Elderly [PACE]) characteristics, and use of specific service types.

RESULTS

Among 21,739 respondents, 23.3% were Black, 3.4% were Asian, 10.8% were Hispanic, 58.8% were non-Hispanic White, and 3.7% were multiracial or identified with other races/ethnicities. Asian and Black consumers had higher odds of reporting unmet need in personal care than White consumers (adjusted odds ratio [aOR], 1.45, p value < 0.01; and aOR, 1.25, p < 0.001, respectively). Asian and Black consumers had significantly higher odds of unmet need in adult day services versus White consumers (aOR, 1.94, p < 0.001 and aOR, 1.39, p < 0.001, respectively). Black consumers had higher odds of unmet need versus non-Hispanic White consumers in meal delivery and caregiver support services (aOR, 1.29; p < 0.01; and aOR 1.26, p < 0.05, respectively). Race and ethnicity were not significantly associated with experiencing unmet need for homemaker/chore or transportation services.

CONCLUSIONS

Future research should identify driving forces in disparities in unmet need to develop culturally appropriate solutions.

Characterizing Caregiver Roles and Conflict in Health Management Support to Older People With Multiple Chronic Conditions

Caregivers provide critical support for older adults managing multiple chronic conditions (MCCs), but few studies describe the assistance caregivers provide or identify factors influencing their provision of support. We conducted qualitative interviews with 25 caregivers to older adults with MCCs to describe caregivers' roles and identify the factors that influence caregivers' ability to carry out these roles. Transcripts were analyzed using the Framework Method. Caregivers supported the management of MCCs in several ways, including monitoring conditions, communicating with clinicians, and tracking health information. Disagreement, or conflicted relationships, between caregivers and older adults over health and behaviors influenced the provision of support, resulting in less involved and less effective caregivers. Caregivers in conflicted relationships were more challenged by resistance from older adults. Greater agreement, or collaboration, between caregivers and older adults resulted in more involved and effective caregivers. Addressing health-related conflict may enhance caregivers' capacity to support older adults with MCCs.

The Effect of Home- and Community-Based Services on Social Engagement

Objectives: Home- and community-based services (HCBS) help older adults to remain active in community settings. However, it is not known if there is a causal relationship between HCBS and social engagement. Methods: We used data from the 2010 and 2012 Health and Retirement Study and measured the effect of HCBS on social engagement via nearest-neighbor Mahalanobis matching, optimal pair matching, genetic matching, and optimal full matching. Results: Genetic matching showed that the odds of social engagement for participants who received at least one HCBS (congregate meal, home-delivered meal, transportation service, case management, homemaker or housekeeping services, or caregiver services) in the prior two years was 1.07 times more likely than participants who have not received any HCBS (robust SE = .030, p = .040). Discussion: HCBS may remove barriers to social engagement through increasing older adults' personal resources and personal networks.

Examining Satisfaction and Quality in Home- and Community-Based Service Programs in the United States: A Scoping Review

BACKGROUND AND OBJECTIVES

Long-term services and supports in the United States are increasingly reliant on home- and community-based services (HCBS). Yet, little is known about the quality of HCBS. We conducted a scoping review of the peer-reviewed literature to summarize HCBS consumer, provider, and stakeholder satisfaction with services as a means of assessing quality.

RESEARCH DESIGN AND METHODS

We searched PubMed, OVID-MEDLINE, and SCOPUS to identify articles published from 2000 to 2021 that reported on studies describing a U.S.-based study population. Articles were grouped into 3 categories: drivers of positive consumer satisfaction, drivers of negative consumer satisfaction, and provider and stakeholder perspectives on satisfaction.

RESULTS

Our final sample included 27 articles. Positive perceptions of quality and reported satisfaction with services were driven by consistent, reliable, and respectful care providers, and adoption of person-centered models of service delivery. Mistreatment of consumers, staff turnover, training, service interruptions, and unmet functional needs were drivers of negative consumer perceptions of quality. Support for caregivers and emphasis on training were identified by providers and stakeholders as important for providing satisfactory services.

DISCUSSION AND IMPLICATIONS

Multiple data challenges limit the ability to systematically evaluate HCBS program quality; however, studies examining single programs found that HCBS consumers are more satisfied and associate higher quality with easy-to-navigate programs and professional staff. Efforts to expand HCBS should also include requirements to systematically evaluate quality outcomes.

Impact of additional community services provision on dementia caregiver burden: an interrupted time-series analysis of 12-year interRAI assessments in Hong Kong

OBJECTIVES

To evaluate the impact of providing additional dementia caregiver support services on caregiver burden.

DESIGN

Interrupted time-series analysis using territory-wide panel data.

SETTINGS

All public-funded district elderly community centres in Hong Kong (HK).

PARTICIPANTS

Primary caregivers for older adults (age over 65 years) living with dementia assessed through International Residential Assessment in HK between 1 October 2004 and 31 September 2016. Paid caregivers were excluded.

INTERVENTIONS

In April 2014, US$280 million was allocated to provide additional psychological support, education and respite care for dementia caregivers in HK.

MAIN OUTCOME MEASURES

Caregiver burden was measured by two age-standardised rates: (1) caregivers in emotional distress; and (2) caregivers with long care time in a week (more than 20 hours a week). We fitted the two time-series into Autoregressive Integrated Moving Average models to evaluate intervention impacts, with follow-up analyses to consider a 6-month transition period of policy implementation. Segmented linear regressions and Holt-Winter exponential smoothening models were used as sensitivity analyses.

RESULTS

36 689 dementia caregivers were included in this study, of which 14.4% caregivers were distress and 31.9% were long-hours caregivers after the policy intervention in April 2014. Providing additional caregiver service significantly reduced standardised rates of caregivers in distress (β (95% CI)=-3.93 (-7.85 to -0.01), p<0.05), but the effect was not sustained (p=0.183). There was no significant impact on the level of age-standardised rates of caregiver with long care time (β (95 CI)=-4.25 (-9.61 to 1.10), p=0.120). Also, there was no significant delay of intervention impacts.

CONCLUSION

Our study finds that strengthening caregiver services provision could reduce distress rates among primary caregivers for older adults living with dementia. Expanding community services for caregiver could be a solution to the escalating burden of informal care for people living with dementia.

A Comparative Case Study Analysis of Barriers and Facilitators to Implementing the Affordable Care Act's Balancing Incentive Program

The Affordable Care Act included the opportunity for states to increase spending on Medicaid home and community-based services (HCBS) for older adults and persons with disabilities through the Balancing Incentive Program (BIP). This study utilized comparative case studies to identify the factors that facilitated or impeded states' implementation of BIP. Findings indicate factors that facilitated the implementation of BIP were communication with the federal government and its contractor, merging BIP with existing HCBS programs, and enhanced federal revenue. On the other hand, the short duration of BIP, state procurement and contracting processes, and the need to incorporate feedback from non-governmental stakeholders and determining how to spend the enhanced revenue proved challenging for some states. This research suggests ways federal and state officials can implement new initiatives to achieve greater rebalancing of Medicaid long-term services and supports for older adults.

Do Income Supplemental Programs for Older Adults' Help Reduce Primary Caregiver Burden? Evidence from Mexico

In countries such as Mexico without formal public long-term care policies, informal care becomes the main source of support for older adults. Alternative social programs, such as supplemental income programs, for older adults could alleviate caregiver burden, especially if supplemental income were to be used for paid care or to compensate non-paid family caregivers. This work is the first to analyze the effects of a supplemental income program for older adults on primary caregiver burden. To identify how such a program might affect caregiver burden, we analyze rich panel data on 433 adults 70 years and older in two communities, one receiving a supplemental income program and the other not, in Yucatan, Mexico. Data were collected in 2008 and 2009 among treatment and control groups before and 6 months after program introduction. We employ a difference-in-differences approach. In our sample, most care is provided by non-paid female caregivers. We find that individuals in both the treatment and control groups received fewer hours of care over time. The decrease was lower for older adults who received the supplemental income, but the difference with those who did not was not statistically significant. We also observe few changes on caregiving burden; even after program introduction, more than 98% of caregivers remained unpaid and the same primary caregiver remained. Altogether, our work suggests supplemental income programs have negligible effects on caregiving, making evident the urgent need for other strategies to support non-paid caregivers who bear most of the burden for old-age care in Mexico.

Towards a universal model of family centered care: a scoping review

Background

Families play an important role meeting the care needs of individuals who require assistance due to illness and/or disability. Yet, without adequate support their own health and wellbeing can be compromised. The literature highlights the need for a move to family-centered care to improve the well-being of those with illness and/or disability and their family caregivers. The objective of this paper was to explore existing models of family-centered care to determine the key components of existing models and to identify gaps in the literature.

Methods

A scoping review guided by Arksey & O’Malley (2005) examined family-centered care models for diverse illness and age populations. We searched MEDLINE, PsycINFO, CINAHL and EMBASE for research published between 1990 to August 1, 2018. Articles describing the development of a family-centered model in any patient population and/or healthcare field or on the development and evaluation of a family-centered service delivery intervention were included.

Results

The search identified 14,393 papers of which 55 met our criteria and were included. Family-centered care models are most commonly available for pediatric patient populations (n = 40). Across all family-centered care models, the consistent goal is to develop and implement patient care plans within the context of families. Key components to facilitate family-centered care include: 1) collaboration between family members and health care providers, 2) consideration of family contexts, 3) policies and procedures, and 4) patient, family, and health care professional education. Some of these aspects are universal and some of these are illness specific.

Conclusions

The review identified core aspects of family-centred care models (e.g., development of a care plan in the context of families) that can be applied to all populations and care contexts and some aspects that are illness specific (e.g., illness-specific education). This review identified areas in need of further research specifically related to the relationship between care plan decision making and privacy over medical records within models of family centred care. Few studies have evaluated the impact of the various models on patient, family, or health system outcomes. Findings can inform movement towards a universal model of family-centered care for all populations and care contexts.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4394-5) contains supplementary material, which is available to authorized users.

Barriers and facilitators to implementing family support and education in Early Psychosis Intervention programmes: A systematic review

Family support is a core component of the Early Psychosis Intervention (EPI) model, yet it continues to have relatively low rates of implementation in practice. This paper reports results of a literature review on facilitators and barriers to delivering family interventions in EPI programmes. A search was conducted of 4 electronic databases, Medline, EMBASE, PsycINFO and Joanna Briggs, from 2000 to 2015 using terms related to early onset psychosis, family work and implementation. Four thousand four hundred and two unique studies were identified, 7 of which met inclusion criteria. Barriers and facilitators were coded and aggregated to higher-level themes using a consensus approach. Five of 7 studies examined structured multifamily psychoeducation. Uptake by families was affected by: family/client interest and readiness to participate; ability to access supports; and support needs/preferences. Implementation by programmes was affected by staff access to training and resources to provide family support. A key finding across the identified studies was that families have different needs and preferences regarding the timing, length, intensity and content of the intervention. One size does not fit all and many families do not require the intensive psychoeducational programmes typically provided. The reviewed literature suggests that flexible, tiered approaches to care may better meet family needs and increase rates of uptake of family support. However, more research is needed on the effectiveness of different models of family support in early psychosis and how they can be successfully implemented.

Progress and Policy Opportunities in Family Caregiver Assessment: Results From a National Survey

Family caregivers play an essential role in long-term services and supports (LTSS). Despite numerous calls for robust caregiver assessment policies to determine needs and treat them as partners in care planning, there has been limited information about whether or how states assess caregiver needs and strengths, or use caregiver information. Using cross-sectional survey data from the 2015 Process Evaluation of the Older Americans Act National Family Caregiver Support Program (NFCSP), this study analyzes caregiver assessment policies and practices in 54 State Units on Aging, 619 Area Agencies on Aging, and 642 local service providers. It examines whether and for what purposes caregiver assessments are used, what domains are included, and how well current policies conform to recommended practice. It also recommends that policy makers who influence NFCSP and other LTSS programs develop caregiver assessment practices using a multidimensional framework including more caregiver-focused domains and utilizing assessment data to measure program outcomes.

Preventive Services Use Among African American and Latino Adult Caregivers in South Los Angeles

BACKGROUND

The burden of informal caregiving is significant and well-documented, yet the evidence is mixed as to whether being a caregiver presents an additional barrier to receiving recommended preventive care.

OBJECTIVES

To determine whether (1) caregivers compared with noncaregivers were less likely to receive preventive health services; and (2) higher intensity caregivers were less likely to receive preventive health services than lower intensity caregivers.

RESEARCH DESIGN, SUBJECTS, AND MEASURES

Data were from a telephone survey of Latino and African American adults 50 years or older in South Los Angeles (n=702). Outcomes were flu vaccination, pneumococcal vaccination, and colorectal cancer screening. Logistic regression models adjusted for predisposing, enabling, and need factors according to the Andersen Model of Access to Health Care for Low-income Populations.

RESULTS

Caregiver type (eg, adult child, nonrelated) was associated with varying odds of receiving a preventive service. Caregivers had lower odds than noncaregivers of receiving preventive services although odds of receiving a flu vaccination improved slightly for caregivers of persons with memory loss compared with other caregivers. More weekly caregiving hours was associated with higher odds of receiving flu vaccination (adjusted odds ratios, 1.1; 95% confidence interval=1.0, 1.1) or colorectal cancer screening (adjusted odds ratios, 1.1; 95% confidence interval=1.0, 1.1). Caregivers and noncaregivers age 65 and older or with chronic conditions were more likely to receive vaccinations.

CONCLUSIONS

Preventive service use was influenced by characteristics of the caregiving situation. An opportunity may exist to leverage care recipients' ongoing contact with health care providers to increase caregivers' own access to preventive services.

"It Just Consumes Your Life": Quality of Life for Informal Caregivers of Diverse Older Adults With Late-Life Disability

Little is known about the quality of life (QoL) for informal caregivers of disabled older adults aged 65+ with diverse backgrounds. Forty-two caregivers were interviewed in English and Cantonese about their caregiving experiences, their recollections of QoL over time, and the factors influencing their appraisals. Overall, 52% of caregivers experienced a decline in QoL. Factors associated with decreased QoL were less time for self, competing financial demands, and the physical and emotional impact of the patient's illness. Factors associated with no change in QoL were minimal caregiving responsibilities, a sense of filial duty, and QoL being consistently poor over time. Factors associated with improved QoL were perceived rewards in caregiving, receiving institutional help, and increased experience. Chinese caregivers were more likely to cite filial duty as their motivator for continued caregiving than were Caucasian caregivers. In conclusion, informal caregivers take on a huge burden in enabling older adults to age in the community. These caregivers need more support in maintaining their QoL.

The VA Caregiver Support Line: A Gateway of Support for Caregivers of Veterans

In passing the Caregivers and Veterans Omnibus Health Services Act of 2010, Congress created a legislative mandate for the Veterans Administration (VA) to strengthen its program of support services for caregivers of veterans. As part of this expansion, the VA implemented a nationwide toll-free telephone Caregiver Support Line (CSL). The CSL is a single point of entry system to link caregivers to national and local services to support care of a veteran. This article describes the CSL and its role in supporting aging veterans and their caregivers, discusses social workers' contributions to its development and implementation, and reports utilization data.

Is Policy Well-Targeted to Remedy Financial Strain among Caregivers of Severely Injured U.S. Service Members?

U.S. military service members have sustained severe injuries since the start of the wars in Iraq and Afghanistan. This paper aims to determine the factors associated with financial strain of their caregivers and establish whether recent federal legislation targets caregivers experiencing financial strain. In our national survey, 62.3% of caregivers depleted assets and/or accumulated debt, and 41% of working caregivers left the labor force. If a severely injured veteran needed intensive help, the primary caregiver faced odds 4.63 times higher of leaving the labor force, and used $27,576 more in assets and/or accumulated debt compared to caregivers of veterans needing little or no assistance.

The caregiving process of the family unit caring for a frail older family member at home: a grounded theory study

AIMS AND OBJECTIVES

To explore the caregiving process of family units caring for a frail older family member at home.

BACKGROUND

Previous research on family caregiving has demonstrated the interdependence between individual members' health and family status and suggested the importance of support provided to the family as a unit. However, little research that could be used as the basis for nursing interventions has focused on the caregiving process of the family unit caring for a frail older family member in the community.

DESIGN

The grounded theory approach was applied in this study.

METHODS

Eighteen families were recruited using the method of theoretical sampling. Data were collected through face-to-face semi-structured interviews. Constant comparative analysis proceeded with data collection.

FINDINGS

Two core categories were identified: 'degree of routinisation of daily life' and 'degree of minimisation of competing needs within the family'. The caregiving process was classified according to the core categories into the following four phases: confusion, fluctuating disharmony, stable disharmony and stable harmony. The conditions for the routinisation and the competing needs and coping strategies of the family were also clarified.

CONCLUSIONS

To lead a stable family life, families caring for a frail older member try to control the competing needs among members and routinise by adopting various strategies. Nurses should support or enhance such family action and interactions.

IMPLICATIONS FOR PRACTICE

The degrees of daily life routinisation and of minimising competing needs within a family can be used to assess families caring for a frail older member. Nurses can determine the current state of the caregiving family from these two aspects and support family strategies that build daily routines and regulate their competing needs.

Unmet home care service needs of rural older adults with Alzheimer's disease: a perspective of informal caregivers

This study assessed unmet service needs of rural older adults with Alzheimer's disease (AD) and identified factors that were related to these needs. Data were collected from 109 informal caregivers of AD patients. Over half of the patients experienced unmet service needs in 1 or more areas of activities of daily functioning. Informal caregiver burden and patient's gender and functional status were significantly related to patients' unmet service needs. Patients' use of formal services was marginally related to their unmet service needs. To better address patients' service needs, a comprehensive needs assessment should be conducted with both patients and their caregivers.

[Tendencies of studies addressing the eldest individuals of aged population in the community: a (inter)national systematic review]

The purpose of this study was to identify and analyze the tendencies and types of studies published in Brazil and abroad, involving elders aged>80 years, living in the community. A systematic review of national literature was performed using the LILACS and SciELO databases, and PUBMED and EMBASE for international literature, covering publications of the last two decades. Twelve national and 162 international references were selected. Biological sciences were the prevalent area both at the national (50%) and international (74.1%) levels. All national studies were observational, 91.7% of which were cross-sectional. Of the international studies, 93.3% were observational, 48.1% of which were cross-sectional and 37.6% were cohort studies. The United States were the country responsible for 41.4% of all international publications. Brazil and China were the only developing countries with international publications. Despite the significant number of international scientific publications as of 2005, this fact has not been observed at the national level.

Support for family caregivers: what do service providers say about accessibility, availability and affordability of services?

This paper reports on a survey of providers of caregiver support services in Singapore (N = 36). The overall aim of the survey was to provide feedback to service planners and programme staff on the delivery of services to caregivers and opportunities for improvement. A questionnaire, comprising both closed and open-ended questions, was used to collect data. The results showed that most health and social service providers offer counselling, case management, caregiver assessment, financial assistance and information. A minority provide emergency, short-stay respite care and day care. About one in three provide transportation services, which featured as a barrier to service utilisation. Other barriers identified were time commitments, lack of awareness of services, cost of care, caregivers' sense of responsibility, lack of alternate care arrangements and distrust. The survey also characterises the hard-to-reach caregivers as homebound, illiterate, socially shy and isolated, of low income and poorly educated. Most service providers emphasise that financial support is necessary in order to improve the prospects of family caregivers.

Racial Differences in Perceived Burden of Rural Dementia Caregivers

This study explores whether religiosity explains racial differences in caregiving burden for a rural sample of dementia family caregivers. Data are from a probability sample of 74 non-Hispanic White and 67 African American dementia caregivers in rural Alabama. SPSS macros for estimating indirect effects in multiple mediator models are used to test the mediation effects of religiosity. White caregivers report higher burden, are less likely to use religious coping, and less likely to engage in organized religion than do African American caregivers. Church attendance is found to significantly ( B = —.57, p < .05) mediate the racial differences on caregiving burden ( R2 = .07). Religious involvement in general, and church attendance in particular, seem to provide both spiritual and social psychological benefits to dementia caregivers. Thus, supplementing formal services with the services provided by religious organizations may be important in rural areas where formal resources are scarce.

Development of the risk appraisal measure: a brief screen to identify risk areas and guide interventions for dementia caregivers

OBJECTIVES

To develop and validate a brief screening measure for use in research, healthcare, and community settings to systematically assess well-being and identify needed areas of support for caregivers of patients with dementia.

DESIGN

This study used data from Resources for Enhancing Alzheimer's Caregiver Health (REACH II), a multisite randomized clinical trial of a behavioral intervention designed to improve the quality of life of caregivers in multiple domains.

SETTING

REACH II.

PARTICIPANTS

Two hundred twelve Hispanic, 211 black, and 219 white family caregivers providing in-home care to patients with dementia.

MEASUREMENT

Based on conceptual and psychometric analyses, a 16-item measure was developed that assesses six domains linked to caregiver risk and amenable to intervention: depression, burden, self-care and health behaviors, social support, safety, and patient problem behaviors. The reliability and validity of the instrument was evaluated with 642 dementia caregiver dyads from the REACH II program.

RESULTS

The measure was found to have acceptable internal consistency for a multidimensional scale and similar measurement properties for each of the racial and ethnic groups. Concurrent validity was also demonstrated for the measure.

CONCLUSION

The REACH Risk Appraisal Measure developed in this study shows promise as an assessment tool that can be used in research, clinical, and community settings to guide, prioritize, and target needed areas of support for caregivers of patients with dementia.

Factors associated with hospital retention of RNs in the New York City Metropolitan Area: an analysis of the 1996, 2000, and 2004 National Sample Survey of Registered Nurses

The nursing shortage is well documented, and government estimates indicate that shortfalls will worsen in the future. As the largest employer of registered nurses (RNs), hospitals are the most seriously affected by shortages, as they compete with other employment settings for limited nursing resources. Recruitment remains the primary avenue for ensuring staffing levels, but retention is increasingly important as applicant pools shrink because of demographic and employment trends. Effective retention strategies must address the factors that contribute to exodus of RNs from hospitals, as well as isolating the factors that enable RNs to remain in hospital employment. This secondary analysis of the 1996, 2000, and 2004 National Sample Survey of Registered Nurses examines the demographic, employment, and educational factors associated with working in hospitals, having full-time status, and holding patient care positions. The findings suggest that hospitals must address nonwork issues to retain nursing personnel. Relevant policy issues are examined and strategies for effective retention are offered.

When the private sphere goes public: exploring the issues facing family caregiver organizations in the development of long-term care policies

Though family caregiving forms the backbone of the long-term care system in the United States, long-term care policies have traditionally focused on paid services that frail older people and people with disabilities utilize for their day-to-day functioning. Part of the exclusion of family caregiving from the long-term care discourse stems from the traditional separation of the private sphere, where family caregiving occurs, from the public sphere of policy making. However, the passage of the Family and Medical Leave Act (FMLA), the National Family Caregiver Support Program (NFCSP) and Medicaid waiver legislation may reflect recent changes in the government's position on their role in addressing issues related to the "private spheres." In this article, we explore the nature of family caregiving in the United States, the divide between the public and private spheres and provide an overview of family caregiving-related policies and programs in the U.S. In our review, we examine the provisions in the FMLA, NFCSP, and Medicaid waiver legislation that support family caregiving efforts. We also examine the roles of family caregiver organizations in making family caregiving an important element of long-term care policy and influencing policy-making.

'Not another form!': lessons for implementing carer assessment in health and social service agencies

This article addresses some of the issues that need to be considered in implementing carer assessment in health and social service agencies. It is based on findings from three studies involving the use of the CARE (Caregivers' Aspirations Realities and Expectations) Assessment Tool in Canada, a comprehensive psychosocial instrument. The first study, carried out between 1999 and 2001, was aimed at developing the CARE Tool, and had as one of its objectives to evaluate the feasibility of its implementation into ongoing practice. The second study, conducted between 2000 and 2003, was designed to evaluate the impact of using the CARE Tool, and also had an objective concerning implementation. A third study was undertaken in 2005-2006, in part, to gain more understanding of the barriers and outcomes of implementing carer assessment. All three studies used focus groups and individual interviews as the main data collection method. In all, this article is based on 13 focus groups and five individual interviews with home care professionals and 19 individual interviews with home care managers or supervisory staff, all having experience with carer assessment. Similar themes emerged from the thematic analyses of the data from all three projects. All studies point to the following as preconditions to successful implementation: clarification of carer status within policy and practice; making explicit agency philosophy with regard to the role and responsibilities of families in care and conceptions of carer assessment; and agency buy-in at all levels. Four themes emerged as issues for implementation: integration of the carer assessment tool with existing tools; ensuring training and ongoing supervision; work organisation and resources required for carer assessment; and logistical questions. It would appear essential that a clear rationale for moving towards carer assessment and its place in a global approach to long-term care and carers are essential to its implementation.

Age and gender of informal carers: a population-based study in the UK

This paper identifies variations in the age and gender characteristics of informal carers in the UK. The paper is based on the Individual Sample of Anonymous Records, a 3% random sample of the 2001 UK Census. The sample size was 1 825 595. Of this sample, 10% were reported to be carers. The analysis shows that informal caregiving is systematically linked with both age and gender. Caregiving increased with age until reaching a peak in the 45-59 age group, in which almost 20% were carers. Similarly, the amount of time spent caregiving increased with age, with the highest levels of caregiving commitment in people aged 80-89 years. Regarding gender, 11.3% of women were carers compared to 8.6% of men and overall women committed more time to caregiving than men. However, this pattern was reversed in later life (70+), where there was a higher proportion of carers and greater time commitment to caregiving amongst men. While the predominance of women as informal carers has been well reported, the importance of men as informal carers in old age is much less commented upon. This study thus suggests that informal caregiving is most prevalent in groups of the population that, according to previous research, may experience most strain from doing so: elderly people who may be frail and often are in a spousal relationship with the care-recipient, and middle-aged women with multiple roles. Therefore, it is of great importance that their particular needs and circumstances are fully taken into account both in the development of formal support and when information about available support is targeted.

Care Needs of Higher-Functioning Nursing Home Residents

OBJECTIVES

To quantify and characterize the chronic conditions of older Americans who live in nursing homes (NHs) but have minimal disability and might be able to live in less restrictive and less expensive settings.

DESIGN

Secondary analysis of the 1999 National Nursing Home Survey.

PARTICIPANTS

NH staff members familiar with the care of residents who were 65 years or older and had resided in the NH for more than 100 days.

MEASUREMENTS

We defined "higher-functioning" residents as those who received help from NH staff in 0-2 activities of daily living. We then classified these higher-functioning residents according to their conditions requiring chronic care: impaired mobility, conditions requiring rehabilitation, mental health disorders, incontinence, severe sensory impairment, and medical conditions (congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, Parkinson's disease).

RESULTS

One-fifth (19.8%) of the NH residents met the criteria for "higher-functioning" (n=1145). Of these, 64.1% had mental disorders, 40.4% had impaired mobility, 20.6% were incontinent, 18% had conditions requiring rehabilitative therapy, 8.7% had severe sensory impairment, and 43.0% had one or more of the four medical diagnoses.

CONCLUSION

Many higher-functioning long-stay nursing home residents have chronic care needs that are similar to those of older adults who live in private residences. Many such persons may be able to live in community settings.

Caregivers of Frail Elders: Updating a National Profile

PURPOSE

Family caregivers comprise the backbone of long-term-care provision in the United States, yet little is known about how the composition and experience of family caregiving has changed over time.

DESIGN AND METHODS

Data are drawn from the 1989 and 1999 National Long-Term Care Survey and Informal Caregiver Survey to develop nationally representative profiles of disabled older adults and their primary informal caregivers at two points in time.

RESULTS

The proportion of chronically disabled community-dwelling older adults who were receiving informal assistance from family or friends declined over the period of interest, whereas the proportion receiving no human help increased. On average, recipients of informal care were older and more disabled in 1999 than in 1989. Primary caregivers were children (41.3%), spouses (38.4%), and other family or friends (20.4%); children were more likely and others less likely to serve as primary caregivers in 1999 relative to 1989. Primary caregivers provided frequent and high levels of help at both points in time. A striking increase was found (from 34.9% to 52.8%) in the proportion of primary caregivers working alone, without secondary caregiver involvement.

IMPLICATIONS

In the context of projected demographic trends and budgetary constraints to public health insurance programs, these data underscore the importance of identifying viable strategies to monitor and support family caregivers in the coming years.