A comparative analysis of disability measures and their relation to home health care use

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.

Performance measures rather than self-report measures of functional status predict home care use in community-dwelling older adults

BACKGROUND

Occupational therapists frequently assess functional status (FS) to determine the home care (HC) service requirements of older adults. However, it is unclear which type of FS measure is most effective for this purpose.

PURPOSE

This study investigated the predictive ability of three measures of FS (a self-report measure of usual behaviour, a self-report measure of capacity, and an observational performance measure-the Performance Assessment of Self-Care Skills [PASS]) on formal HC utilization.

METHOD

A secondary analysis of 2001 Aging in Manitoba Longitudinal Study (AIM) data was conducted.

FINDINGS

The odds of receiving HC within the 30-month follow-up period were 1.32 times (or 30%) higher for each increase in the number of dependent tasks based upon a standardized performance measure. The self-report measures did not predict HC utilization.

IMPLICATIONS

This study suggests that standardized performance measures-in particular, the PASS-are more predictive of formal HC use in community-dwelling older adults than self-report measures.

Costs and determinants of privately financed home-based health care in Ontario, Canada

The Canadian context in which home-based healthcare services are delivered is characterised by limited resources and escalating healthcare costs. As a result, a financing shift has occurred, whereby care recipients receive a mixture of publicly and privately financed home-based services. Although ensuring that care recipients receive efficient and equitable care is crucial, a limited understanding of the economic outcomes and determinants of privately financed services exists. The purposes of this study were (i) to determine costs incurred by families and the healthcare system; (ii) to assess the determinants of privately financed home-based care; and (iii) to identify whether public and private expenditures are complements or substitutes. Two hundred and fifty-eight short-term clients (<90 days of service utilisation) and 256 continuing care clients (>90 days of utilisation) were recruited from six regions across the province of Ontario, Canada, from November 2003 to August 2004. Participants were interviewed by telephone once a week for 4 weeks and asked to provide information about time and monetary costs of care, activities of daily living (ADL), and chronic conditions. The mean total cost of care for a 4-week period was $7670.67 (in 2004 Canadian dollars), with the overwhelming majority of these costs (75%) associated with private expenditures. Higher age, ADL impairment, being female, and a having four or more chronic conditions predicted higher private expenditures. While private and public expenditures were complementary, private expenditures were somewhat inelastic to changes in public expenditures. A 10% increase in public expenditures was associated with a 6% increase in private expenditures. A greater appreciation of the financing of home-based care is necessary for practitioners, health managers and policy decision-makers to ensure that critical issues such as inequalities in access to care and financial burden on care recipients and families are addressed.

Aggregated measures of functional disability in a nationally representative sample of disabled people: analysis of dimensionality according to gender and severity of disability

OBJECTIVE

To determine (i) the dimensional invariance of instrumental and basic activities of daily living (IADL/ADL) by gender subgroups, and (ii) the extent to which ADL dimensionality varies with the inclusion or exclusion of nondisabled people.

METHODS

Data were taken from the 1999 Spanish Survey on Disability, Impairment and State of Health. The analysis focussed on 6,522 people aged over 65 years who received help to perform or were unable to perform IADL/ADL items. Unidimensional and multidimensional item response theory (IRT) models were applied to this sample.

RESULTS

In the female sample, IADL/ADL items formed a scale with sufficient unidimensionality to fit a two-parameter logistic IRT model. In the male sample, the structure was bidimensional: self-care and mobility, and household activities. When the sample was composed of IADL/ADL disabled people, ADL items formed a unidimensional scale; when it was composed only of ADL disabled people, they formed a bidimensional structure: self-care and mobility.

CONCLUSIONS

IADL/ADL items can be combined in a single scale to measure severity of functional disability in females, but not in males. Separate aggregated scores must be considered for each subdomain, basic mobility and self-care, in order to measure the severity of ADL disability.

Aging in Place? Evidence That a State Medicaid Waiver Program Helps Frail Older Persons Avoid Institutionalization

Long-term care will increasingly shift from institutions to home and community based services. Using data from a Medicaid home care waiver program in South Carolina, the Community Long-Term Care (CLTC) program, we evaluated differences in frailty and service use among CLTC clients between 1995 (n = 3,748) and 2005 (n = 9,157). The expectation was that CLTC clients had become more frail in that period, and had greater access to services in the community, results that might suggest the CLTC program had helped individuals to avoid institutionalization. Frailty measures included acute and chronic conditions, other health conditions, and activities of daily living (ADL). We evaluated the percentage of clients using services, and service use intensity. A large majority of clients in both years were impaired in at least four ADL. In 2005, CLTC clients were significantly more likely to have chronic conditions, including hypertension, chronic obstructive pulmonary disease, Alzheimer's disease, arthritis, diabetes, and renal failure (all p < 0.05). Clients were significantly more likely to receive specific services in 2005, including physical therapy, dialysis, and oxygen (all p < 0.05). Results suggest CLTC participants were more frail in 2005 than in 1995. This may reflect a successful effort to help individuals age in place in the community, delaying institutionalization. States may be able to control increases in Medicaid long-term care costs through home care programs that delay institutionalization.

Scales and tales: older women's difficulty with daily tasks

OBJECTIVES

Part of a 3-year study of the home care experience among 25 older women (aged 80-96), this research aimed to describe how the women understood difficulty relative to 20 basic and instrumental activity of daily living tasks.

METHODS

This was a qualitative study with a quantitative component. During open-ended interviews about living alone with help, participants rated difficulty with tasks on a 1-to-5 scale and talked about difficulty relative to tasks. I estimated concordance of the first two ratings and used a descriptive phenomenological method to discern how participants understood difficulty.

RESULTS

Concordance was satisfactory for all tasks other than climbing stairs. Six elements of the life-world of older women were descriptive of difficulty relative to tasks, including pinpointing my biggest/hardest job and having difficulty rating difficulty. Whether reporting difficulty or not, some women spoke of taking extra time, extra effort, or both.

DISCUSSION

The findings suggest a counterview to functional limitation models. Difficulty was posed as a theoretical construct, and the concept of subliminal difficulty was introduced. Various facets of difficulty warrant further descriptive work. Incorporating an opportunity to talk about difficulty, as well as to rate it, would be valuable in large-scale studies.

Problems with preparing food reported by frail older women living alone at home

Although nutritional risk is a critical health concern for older persons, there are few data about day-to-day problems with nutrition-related tasks. Such data were reported by 18 frail women during a longitudinal descriptive phenomenological study of the home care experience. Six problems were understood as elements of the life-world of older women, including having trouble figuring out what to fix, having trouble getting the food cooked right, and struggling with moving and standing while cooking. The results suggest topics for research and underscore the need for partnership between frail older women and helpers relative to food preparation.

The Health Trade-off of Rural Residence for Impaired Older Adults: Longer Life, More Impairment

CONTEXT

Years lived with and without physical impairment are central measures of public health.

PURPOSE

We sought to determine whether these measures differed between rural and urban residents who were impaired at the time of a baseline measurement. We examined 16 subgroups defined by rural/urban residence, gender, race, and education.

METHODS

This is a 20-year retrospective cohort study, following 2,939 Americans who were aged 65-69 in 1982 and physically impaired at the time of the baseline measurement, with data from the National Long-Term Care Survey. Interpolated Markov chain analysis and microsimulation estimated life expectancy at age 65 and expected number of years with physical impairment. Impairment was defined as requiring help in 1 or more activities of daily living.

FINDINGS

Among older individuals with physical impairments at baseline, rural residents lived notably longer than urban residents. In all but 1 group, rural residents lived more years with physical impairment, and they also had a notably larger proportion of remaining life impaired.

CONCLUSIONS

Results suggest a notable public health impact of rural residence for impaired individuals, a longer expected period of impairment. Needs for services for people with impairments may be greater in rural areas.

Actions taken by frail older widows to allow home care providers access to their homes

Nurses have been advised to encourage older persons to keep their doors locked, but there is little guidance about how home care providers should best gain access to the homes of clients. During a descriptive phenomenological study of the experience of home care (N = 25), 9 frail older women explained their strategies for allowing providers access to their homes. Women who typically left their doors open for their own reasons were not uncomfortable leaving the door open when a provider was expected. However, women who left the door unlocked at the request of a provider expressed misgivings about doing so. Older women need personalized counseling about ensuring access to care providers while maximizing safety. For practical, ethical, and legal reasons, home care providers who ask older women to leave their doors open should reconsider that strategy.

Home- and Community-Based Service Use by Older African American, Hispanic, and Non-Hispanic White Women and Men

This study examined associations between use of home- and community-based services and race, ethnicity, and gender. Using the 1994 Second Longitudinal Study of Aging (n = 9,447) and descriptive, standard logistic, and multinomial logistic analyses, both the likelihood of service use and intensity of use were examined for nine home- and community-based services. In descriptive analyses, African Americans used the largest number of services, followed by Hispanics, and non-Hispanic whites. In multivariate results, all compared with non-Hispanic white women, African American women had higher odds of using Personal Care Aides, Transportation, Adult Day Centers, and Information and Referral. Hispanic women had higher odds of using Adult Day Centers and Transportation services. Non-Hispanic white men were less likely to use Personal Care Aides, Senior Centers, and Transportation. In the intensity analysis, compared with non-Hispanic white women, African American women used services more intensively. Non-Hispanic white men used services less intensively. Results highlight the need for flexibility in services provision, and a continued emphasis on supporting a range of services.

Racial and ethnic disparities in the outcomes of elderly home care recipients

The purpose of this study was to examine racial/ethnic disparities in functional outcomes of elderly home health care recipients. Analyses were conducted using Outcome and Assessment Information Set (OASIS) data for a nationally representative sample of home health care episodes for patients aged 65 and older. Risk-adjusted regression analyses examined the association between race/ethnicity and functional outcomes. Fourteen outcome measures reflected improvement in specific functional areas (e.g., ambulation) and two reflected overall functional change. Non-Hispanic Whites (Whites) experienced substantially better functional outcomes than did home health care recipients of other racial/ethnic backgrounds. The disparity in outcomes was most pronounced between Whites and African Americans.

Older Widows' Expectations of Home Care Nurses

The concept of expectations has been integral to research on home care satisfaction, but little is known about expectations of home care. The aim of this longitudinal phenomenological study was to describe part of the personal-social context of older widows' experience of home care-that of holding expectations of home care nurses. Data were drawn from interviews over three years with the 11 women who had home care nurses. The context of the home care experience was featured by leaning on helpers more at this stage and by expecting the nurse to do what the nurse is supposed to do, with its five parts including expecting the nurse to know how to do what needs to be done. Findings exemplified conceptual overlap among standard realms of expectations, such as behaviors and outcomes, and revealed the relevance of such data in appraisals of home care quality.

Older Widows' Experience of Home Care

BACKGROUND

Scholars and practitioners have defined home care as a set of services that older persons receive at home. There have been few empirical studies of the essence of the experience.

OBJECTIVES

To describe the experience of home care for older widows living alone in their own homes. Findings are reported from one aim of the study, which was to discern the phenomena that were descriptive of the experience of the sample as a whole.

METHOD

A descriptive phenomenological method was used. Participants met inclusion criteria for duration of widowhood, continuing residence in their own homes since the husband's death, number of adult children, self-rated health, and study-specific mental competence. Over a 3-year period, seven tape-recorded interviews were conducted in the homes of 25 widows over the age of 80. Foci of interest were the women's perceptions, actions, and intentions relative to their helpers and the help they had while living alone. The structures of the experience and its context were discerned and detailed in the form of taxonomies of phenomena and contextual features.

RESULTS

The common phenomena were sorting out who can best do what needs to be done, protecting my standby, mobilizing my standby to help with this job too, and working together to get the job done. A new definition of home care was proposed, incorporating those phenomena.

DISCUSSION

These older widows were not merely receiving home-care services. They were negotiating reliance on their standby helpers in specific ways. As home-care nurses plan care with widows and their other helpers, they should set aside standard definitions of home care that pertain to providing services and focus on the intentions of the older widows whom they serve.