Effective coordination of medical and supportive services

A protocol for a multi-site cohort study to evaluate child and adolescent mental health service transformation in England using the i-THRIVE model

The National i-THRIVE Programme seeks to evaluate the impact of the NHS England-funded whole system transformation on child and adolescent mental health services (CAMHS). This article reports on the design for a model of implementation that has been applied in CAMHS across over 70 areas in England using the 'THRIVE' needs-based principles of care. The implementation protocol in which this model, 'i-THRIVE' (implementing-THRIVE), will be used to evaluate the effectiveness of the THRIVE intervention is reported, together with the evaluation protocol for the process of implementation. To evaluate the effectiveness of i-THRIVE to improve care for children and young people's mental health, a cohort study design will be conducted. N = 10 CAMHS sites that adopt the i-THRIVE model from the start of the NHS England-funded CAMHS transformation will be compared to N = 10 'comparator sites' that choose to use different transformation approaches within the same timeframe. Sites will be matched on population size, urbanicity, funding, level of deprivation and expected prevalence of mental health care needs. To evaluate the process of implementation, a mixed-methods approach will be conducted to explore the moderating effects of context, fidelity, dose, pathway structure and reach on clinical and service level outcomes. This study addresses a unique opportunity to inform the ongoing national transformation of CAMHS with evidence about a popular new model for delivering children and young people's mental health care, as well as a new implementation approach to support whole system transformation. If the outcomes reflect benefit from i-THRIVE, this study has the potential to guide significant improvements in CAMHS by providing a more integrated, needs-led service model that increases access and involvement of patients with services and in the care they receive.

Factors related to satisfaction with long-term care services among low-income Korean elderly adults: A national cross-sectional survey

BACKGROUND

With the growing demand for long-term care (LTC) services, it is increasingly important to explore experience with care. This study examined care satisfaction in a nursing home and at home among low-income elders in South Korea.

METHODS

This cross-sectional study was conducted with 246 elderly recipients of welfare benefits using a proportional stratified sampling method. Two self-reported versions of a questionnaire developed for users of nursing home care and homecare were used.

RESULTS

Those at home reported higher care satisfaction than those in nursing homes did. Both users of nursing home care and homecare were less satisfied with the food served. Users of nursing homes had comparatively less satisfaction regarding the daily activities available to them and less autonomy concerning their care decisions. Factors that influenced satisfaction with nursing home care and homecare were the quality of caregivers, care facilities, and physical wellbeing.

CONCLUSIONS

An approach focused on improving the quality of the care facilities and caregivers could help enhance care satisfaction among low-income Korean elders receiving LTC.

Older Widows’ Speculations and Expectancies Concerning Professional Home-Care Providers

Little is known about older persons’ expectancies (or anticipations) about the possible actions of home-care professionals, although such data have implications for the ethics of home care and home-care policies. From a longitudinal study of older women’s experience of home care, findings are reported concerning their expectancies of professional home-care providers. A descriptive phenomenological method was used to detail the structure of the experience and its context. Data were analyzed from a series of interviews with 13 women aged 82 to 96 years. Among the five key structures of experience were ‘finding that someone has the job of helping me here’ and ‘determining where the helper’s field lies’. Two subsets within a category of expectancies were differentiated: speculations about helpers’ possible actions and expectancies about outcomes of helpers’ actions. As parameters of relational ethics, clients’ speculations and expectancies are appropriate bases for dialogue about older widows’ relationships with home-care professionals and the foci of home-care policies.

Health and social services integration: a review of concepts and models

Health and social services integration is particularly relevant for populations whose needs span physical health, mental health, housing, and disability services, along with others. Veterans, homeless, chronically ill, and aging are among those populations. This review examines recent peer-reviewed literature about different approaches to services integration, rationales behind those approaches, and successes of those approaches, including factors that make them succeed or fail. The focus here is on services that cross disciplinary boundaries; that is, those that integrate health services with social services, health services with mental health services, or one social service with a categorically different social service.

Barriers and facilitators to optimize function and prevent disability worsening: a content analysis of a nurse home visit intervention

AIMS

This paper is a report of an analysis of how to better understand the results of the nurse home visit intervention in the Medicare Primary and Consumer-Directed Care Demonstration in terms of facilitators and barriers to disability improvement/maintenance as compared with disability worsening.

BACKGROUND

There is a lack of literature describing how nurse home visit interventions are able to maintain/improve disability among older persons with disability. The present study is one of only six reporting beneficial disability outcomes.

METHODS

Cases were purposefully sampled to represent change in the disability construct leading to selection of ten cases each of disability maintenance/improvement (no change or decrease in total Activities of Daily Living score from baseline) and worsening (an increase in total Activities of Daily Living score from baseline). Data from nurses' progress notes and case studies (collected in March 1998-June 2002) were analysed using qualitative descriptive analysis (May 2009). These results remain relevant because the present study is one of the few studies to identify select nurse activities instrumental in postponing/minimizing disability worsening.

RESULTS/FINDINGS

Three primary themes captured the facilitators and barriers to effective disability maintenance/improvement: (1) building and maintaining patient-centred working relationships, (2) negotiating delivery of intervention components and (3) establishing balance between patients' acute and chronic care needs. Sub-themes illustrate nurse, patient and system factors associated with effective disability maintenance/improvement (e.g. nurse caring, communicating, facilitating interdisciplinary communication) and barriers associated with disability worsening (e.g. dementia, depression and recurring acute illnesses).

CONCLUSION

This study provides new insights about the facilitators and barriers to effective disability maintenance/improvement experienced by patients receiving home visits. Potential opportunities exist to integrate these insights into best-practice models of nurse home visiting.

Long-term care in the United States: policy themes and promising practices

This analysis provides an overview of the major policy themes and promising practices emerging in recent years as policymakers and researchers struggle to design a long-term care system that meets the needs of an aging population. Themes that have dominated the long-term care policy debates include: recruiting and retaining a qualified long-term care workforce; devising financing mechanisms for those requiring long-term care; and moving away from an institutional-based long-term care system towards more home- and community-based services. Three promising practices that have emerged in the past few decades include: the culture change movement; service integration that combines medical and social care; and various forms of community residential care that bring together housing and services in a more home-like environment. It concludes with long-term care recommendations for policymakers.

Social support and caregiving circumstances as predictors of caregiver burden in Taiwan

Previous research has failed to consider the importance of caregiving circumstances and their impact on social support and caregiver burden. Hence, this study aimed to investigate the association between perceived and received social support and caregiver burden. This cross-sectional study was carried out on 301 family caregivers. Data was collected using structured questionnaires which included a Social Support Scale, Family APGAR (adaptation, partnership, growth, affection, resolve), and Caregiver Burden Scale. Findings showed that the caregiver burden was best predicted by two perceived and one received social support variables. Caregiver burden was likely to be higher when the caregivers had lower levels of family function and social support. Perceived social support was better at predicting caregiver burden than received social support. Our study indicates that family function has an important influence on caregiver burden. Further studies on family based interventions are needed to determine approaches for effectively reducing caregiver burden. The role of perceived social support in the health of caregivers should be further investigated as a possible protective determinant in the caring process.

Community-Based Care Model for High-Risk Adults with Severe Disabilities

Objective: Evaluate the effectiveness of a home-based intervention for adults with serious physical disabilities at high risk for poor health outcomes.

Design: A pretest/post-test design; content analysis of case studies.

Setting: Five-county Philadelphia metropolitan area.

Patients and Other Participants: Forty-nine community-dwelling adults aged 20—55.

Intervention: Six-month comprehensive care management intervention implemented by Advanced Practice Nurses (APNs) focused on improvement of functional status or prevention of functional decline; management of health problems; and enhancement of self-direction of care by subjects and caregivers.

Main Outcome Measures: Functional status; total hospitalizations, emergency department (ED) and acute care physician visits; symptom management; depression; quality of life; and satisfaction with care.

Results: Between baseline assessment and nine months post-APN intervention, functional status improved (mean = 33.42 → 24.97, p = 0.014). There was a trend toward reductions in average hospitalization rate from 1.10 at baseline to 0.68 nine months post-APN intervention and ED rates from 0.90 to 0.50. Acute care visits to physicians increased from 0.52 to 0.95 from baseline to nine months post-APN intervention. The use of home health aides (mean = 2.72 → 1.37, p = 0.008) and physical therapists (mean = 1.16 → 0.42, p = 0.001) also decreased from baseline to nine months post-APN intervention. Facilitators and barriers to care are identified.

Conclusions: Findings suggest potential benefit of a comprehensive, individualized intervention coordinated by APNs in improving health and functional outcomes and decreasing the use of

Preferences for accepting prescribed community-based, psychosocial, and in-home services by older adults

The purpose of this study was to describe the preferences of minority and non-Hispanic White home bound older adults aged 60 and over for making decisions to accept and arrange community-based, psychosocial, and in-home services prescribed by Home Health clinical social workers (N=249). Overall, prescribed community-based, psychosocial, and in-home service referrals were accepted by participants. In-home supportive services, Short- and Long-Term Case Management, and Psychiatric Nurse were the most frequently arranged services by clinical social workers. Resistance by both minority and non-Hispanic Whites to the arrangement of services was evident for several other services. Social workers, case managers, and other professionals involved in the arrangement and planning of services for similar older adults can use the results to gain an understanding of both the specialized services prescribed by clinical social workers to functionally dependent older adults and the decisions older adults make to accept and/or arrange such services.

The public/private partnership behind the Cash and Counseling Demonstration and Evaluation: its origins, challenges, and unresolved issues

OBJECTIVE

To discuss why and how the Cash and Counseling Demonstration came to be designed, implemented, and evaluated through a partnership between the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the Robert Wood Johnson Foundation (RWJF).

PRINCIPAL FINDINGS

This public/private partnership was created by two colleagues who were motivated by the need for funding to conduct a large-scale demonstration and evaluation, the prestige that both organizations brought to the project, the ability to draw on both organizations' experience and expertise, and the potential to maximize flexibility in the design and implementation of the demonstration. The partnership, which has lasted over a decade and has supported two generations of Cash and Counseling programs, overcame several challenges including getting approval for the project through their respective bureaucracies, managing the decision making process and the ongoing program across the two organizations, dealing with leadership and staff turnover, and reaching consensus on how to apportion credit for the success of the program. Several unresolved issues remain, including how the program gets operationalized within each state, how case management is addressed within the context of a consumer-directed model like Cash and Counseling, how quality is assured in this type of program, and how the Internal Revenue Service views and treats Cash and Counseling and other consumer-directed programs.

CONCLUSION

This public/private partnership is an illustration of how public dollars can be leveraged effectively to examine a pressing policy issue and to produce information that can be translated into better policy and practice. The ASPE/RWJF collaboration made it possible to develop, test, and expand a policy-oriented demonstration project that has become a pivotal strategy in most states' efforts to build their home and community-based service systems.

Setting eligibility criteria for a care-coordination benefit

OBJECTIVES

To examine different clinically relevant eligibility criteria sets to determine how they differ in numbers and characteristics of individuals served.

DESIGN

Cross-sectional analysis of the 2000 wave of the Health and Retirement Study (HRS), a nationally representative longitudinal health interview survey of adults aged 50 and older.

SETTING

Population-based cohort of community-dwelling older adults, subset of an ongoing longitudinal health interview survey.

PARTICIPANTS

Adults aged 65 and older who were respondents in the 2000 wave of the HRS (n=10,640, representing approximately 33.6 million Medicare beneficiaries).

MEASUREMENTS

Three clinical criteria sets were examined that included different combinations of medical conditions, cognitive impairment, and activity of daily living/instrumental activity of daily living (ADL/IADL) dependency.

RESULTS

A small portion of Medicare beneficiaries (1.3-5.8%) would be eligible for care coordination, depending on the criteria set chosen. A criteria set recently proposed by Congress (at least four severe complex medical conditions and one ADL or IADL dependency) would apply to 427,000 adults aged 65 and older in the United States. Criteria emphasizing cognitive impairment would serve an older population.

CONCLUSION

Several criteria sets for a Medicare care-coordination benefit are clinically reasonable, but different definitions of eligibility would serve different numbers and population groups of older adults.

A Proposal for a Voucher System for Long-Term Care in Hong Kong

Over the next three decades, due to a rapidly aging population coupled with the recent economic downturn, Hong Kong society will face severe challenges in establishing a sustainable aged care system. We identify four principles: the encouragement of family care, service integration, a mixed mode of financing, as well as a "small government and large market" approach to guide the development of aged care services. After a brief description of existing Hong Kong long-term care services for the elderly, we evaluate this service according to these principles. We examine how a proposed voucher system could tackle problems in the current system of long-term care. Finally, we propose solutions to alleviate the possible negative consequences of the voucher system and describe the essential preconditions for the full implementation of the system.

Medicare and Medicaid Home Health and Medicaid Waiver Services for Dually Eligible Older Adults: Risk Factors for Use and Correlates of Expenditures

PURPOSE

The purpose of this work was to, among frail dually eligible older adults, determine risk factors for the likelihood of using Medicare home health and Medicaid home health services and to, among service users, determine correlates of Medicare home health, Medicaid home health, and Medicaid waiver service expenditures.

DESIGN AND METHODS

Dually eligible individuals enrolled in Connecticut's Medicaid home- and community-based services (HCBS) waiver program for the aged (N = 5,232) were identified from a statewide database containing person-level linked data from Medicare claims, Medicaid claims, and uniform clinical assessment forms. Expenditures, based on claims data, were observed from the month following clinical assessment over the period August 1995 to December 1997.

RESULTS

In multivariate models controlling for medical conditions and sociodemographic variables, similar functional disability measures were strongly associated with the probability of the use of, and expenditures for, Medicare home health and Medicaid home health services; severe cognitive impairment was strongly associated with greater Medicaid waiver service expenditures.

IMPLICATIONS

Given the similarity of factors associated with Medicare and Medicaid home health service use and expenditures, greater integration of Medicare and Medicaid financing, reimbursement, and delivery strategies for home health services may be feasible and warranted for dually eligible older adults enrolled in state Medicaid HCBS waiver programs.

Case management: who needs it? Does it work?

Even after 30 years of experience, two questions persist about case management practice. Who needs it and does it work? Answers to these questions are neither direct nor simple. This article examines the significance of various contexts (policy, system, community, and organization) to efforts attempting to provide responses to these basic questions. Beyond the question of who needs case management, two additional questions are addressed. Who needs it and who gets it? Clients' qualitative perspectives on case management effectiveness, beyond attempts to measure satisfaction and quality of life, are usually absent. The article concludes with a discussion of whether these are the right questions.