How state-funded home care programs respond to changes in Medicare home health care: resource allocation decisions on the front line

OBJECTIVE

To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment.

DATA SOURCES/STUDY SETTING

Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders.

STUDY DESIGN

Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N = 2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices.

DATA COLLECTION/EXTRACTION METHODS

Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients.

PRINCIPAL FINDINGS

Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels.

CONCLUSIONS

Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics.

The relative effects of home care client characteristics on the resource allocation process: do personality and demeanor matter?

PURPOSE

This study measures the differential effects of home care client characteristics typically included in standardized needs assessment protocols, and client characteristics such as attitude or demeanor that arise from the case manager-client interpersonal dynamic during the assessment process, on care plan decisions.

DESIGN AND METHODS

Three hundred fifty-five case managers in Massachusetts' state-funded home care program for elderly persons selected care plan eligibility levels for 2,054 vignette clients generated in accordance with a previously devised factorial vignette survey methodology. Robust regression models estimated the effects of standardized and nonstandardized elderly client characteristics on care plan eligibility level.

RESULTS

Client characteristics of physical functioning, psychological functioning, and resources best predicted care plan generosity, in accordance with home care program policy to match services with standardized cues of client need. Nonstandardized client characteristics, however, also significantly predicted care plan generosity. Clients who denied needing home care services were allocated less generous care plans than clients who were passive and appreciative service recipients. This finding persisted when controlling for client disability level and cognitive status. Social work licensure increased this effect.

IMPLICATIONS

Results indicate the importance of considering how both standardized and nonstandardized cues of client need affect home care policy implementation. Findings suggest that, although case managers recognize the importance of integrating client care preferences into care planning, additional training is needed to support complex considerations of client autonomy.