Unmet patient need in home care under managed care

Emotional demands and the risks of depression among homecare workers in the USA

PURPOSE

Homecare workers' diversity of emotional demands and their relation to mental health problems have not yet been fully explored. The purpose of this study is to investigate the types of emotional demands on homecare workers and the association of these demands with depression.

METHOD

Data were collected from two surveys of a random sample of 1,599 homecare workers (June 2003-September 2003 and December 2003-February 2004). Depression was assessed using a 20-item RCES-D screening scale.

RESULTS

Homecare workers appeared to have a variety of emotional demands: unfair treatment, client's family abuse, unmet care needs, client health, and emotional suppression. In general, homecare workers were more likely to be exposed to their client health and emotional suppression (mean scores = 1.46-3.07) than to be exposed to unmet care needs, unfair treatment, and client's family abuse (mean scores = 1.02-1.38). After adjusting for potential confounders, four emotional-demand factors (excluding the client health factor) were significantly associated with a high risk of subthreshold depression at Wave 1. In particular, the factor "unmet care needs" was an essential predictor of 6-month subthreshold depression at Wave 2.

CONCLUSION

This study illustrated the diversity of emotional demands among homecare workers and their association with depression. Our mixed findings regarding the cross-sectional and longitudinal analyses suggested that further research should refine the measurement of emotional demands and their relationship with mental health among homecare workers.

Psychosocial Care in Home Health Policy

As of summer 2008, health care reform has become an important part of the 2008 presidential election. However, long-term care has been absent in the discussion of health care reform by presidential candidates. This article examines policies that govern the payers of long-term care, specifically home health care (HHC). HHC is the fastest growing industry within long-term care, as there is a growing number of older adults in need of both skilled and unskilled home care. Medicare and Medicaid are the two major payers of HHC; yet these payers do not address the psychological and social needs of the patients. Furthermore, there is a long-term care disconnect between Medicare and Medicaid that creates even larger problems for older adults in need of long-term care.

Evidence-based Research Challenges Home Care PPS Patient Benefits, Costs, and Payment Structure

A neglected area of discussion in home care is the relationship and dissonance between evidence-based research on effective home and community-based interventions, Medicare home health practice, and the Medicare Home Health Prospective Payment System (PPS). PPS is critical because the literature increasingly indicates that the PPS reimbursement framework drives home health agency and practitioner resource allocation and practice decisions. However, the PPS system does not have an evidence-based evaluation process to evaluate the effectiveness and cost-effectiveness of new, or existing, intervention. The article reviews existing evidence-based research on the effectiveness of home-based environmental skills building, counseling, and support group interventions, which benefit patients, caregivers, home health agencies, and Medicare. The article indicates these interventions have never been evaluated, nor are they covered by Medicare. The article asserts the need for such an evaluation process to evaluate intervention cost-effectiveness and related changes in Medicare coverage, eligibility, reimbursement, and outcomes measurement criteria necessary for their adoption.

Advancing the evidence base for social work in long-term care: the disconnect between practice and research

This article reviews the research literature relative to social work practice in geriatric long-term care (LTC) settings with the aim of determining the state of the evidence base for practice. Overall, this body of research supports the efficacy of social work services within the context of community-based case management and interdisciplinary models of geriatric intervention; however, there is less evidence of a discipline-specific contribution, particularly in institutional health care settings (e.g., nursing homes and hospitals) where a great number of gerontological social workers are employed. Implications of this review include the need to prioritize research within gerontological social work in order to enhance best practice knowledge and skills in settings where it is most needed.