Consumer-Directed Supports: Economic, Health, and Social Outcomes for Families

Self-Directed Home- and Community-Based Services Improve Outcomes for Family Caregivers: A Systematic Review

BACKGROUND AND OBJECTIVES

Self-direction is an approach that allows older adults and people with disabilities to determine the home- and community-based services they receive, including the ability to hire caregivers of their choice. Self-direction has been shown to improve outcomes for the service recipients. The promotion of choice and control in self-direction may also affect family caregivers. We conducted a systematic review examining the impact of self-direction on a broad range of caregiver outcomes.

RESEARCH DESIGN AND METHODS

We conducted a systematic review guided by PRISMA guidelines. Literature search was conducted in 8 databases. We appraised risk of bias using the Joanna Briggs Institute critical appraisal checklists and assessed certainty of evidence using the GRADE framework.

RESULTS

Sixteen studies meeting inclusion criteria were included. We found, with moderate certainty, that self-direction is associated with improved caregivers' personal and social well-being. Caregivers also reported reduced unmet needs and increased access to care for the care recipients under self-direction. Self-direction did not appear to reduce caregiving hours. With less certainty, self-direction was also positively associated with increased respite care use, perception of choice, and intention to continue caregiving by caregivers.

DISCUSSION AND IMPLICATIONS

Beyond delivering person-centered services that improve recipient outcomes, self-direction may also improve the outcomes of family caregivers.

Impact of severe polyhandicap cared for at home on French informal caregivers' burden: a cross-sectional study

OBJECTIVES

Polyhandicap (PLH), defined by a combination of profound intellectual impairment and serious motor deficits, is a severe condition with complex disabilities. In France, care of the large majority of PLH individuals is managed in specialised rehabilitation centres or residential facilities, but some of PLH individuals are cared for at home. The aims of this study were to assess the self-perceived burden among informal caregivers of PLH individuals and to identify potential determinants of this burden.

DESIGN

Cross-sectional study (Neuropaediatric Department, Trousseau Hospital, Paris, France).

SETTINGS

PLH children were recruited from a specialised paediatric/neurological department.

PARTICIPANTS

The selection criteria of caregivers were age above 18 years and being the PLH individual's next of kin.

OUTCOMES MEASURES

From March 2015 to December 2016, data were collected from the caregivers, including sociodemographical data, health status, psycho-behavioural data (quality of life, mood disorders and coping) and self-perceived burden. In addition, the health status of the PLH individual was collected. Relationships between the burden scores and potential determinants were tested (correlations coefficients, Mann-Whitney tests, generalised estimating equations models).

RESULTS

Eighty-four children were eligible; 77 families returned their questionnaire. The informal caregivers of PLH children experienced a high level of perceived burden (scores ranged from 55±20 to 81±12). Eighty per cent of them had more than 5 hours of daily caregiving and 51% of them had to get up more than twice during the night. The main factors associated with caregiver burden were age, financial issues, health status, daily care and coping strategies. The patients' health status was not associated with caregiver burden.

CONCLUSIONS

Some of the caregiver burden determinants might be modifiable. These findings should help healthcare workers and health-decision makers implement specific and appropriate interventions.

TRIAL REGISTRATION NUMBER

NCT02400528.

Longitudinal appraisals of family caregiving for people with disabilities enrolled in Medicaid managed care

Objective: To longitudinally examine the impact of public family support on appraisals of caregiving burden, satisfaction, and self-efficacy among families of adults with disabilities.Background: Little research exists on family support and the family experience within Medicaid managed care across disabilities and longitudinally.Method: Illinois Medicaid managed care enrollees with disabilities and their family members completed surveys over 2 years. Only families and enrollees who lived together were included (N = 182 pairs).Results: Family members with more unmet family support needs had increased caregiving burden and decreased satisfaction and self-efficacy. Family members providing more unpaid care reported higher burden. Black family members had significantly lower burden, and parents had significantly lower satisfaction and self-efficacy. Family members of enrollees with intellectual and developmental disabilities had higher self-efficacy.Conclusion: Family support is important to caregiving appraisals.Implications: There is a need for including family needs for services within assessments for services and within policy.Implications for rehabilitationFamilies provide a substantial amount of care for their family members with disabilities.More family support for family caregivers of people with disabilities is related to better caregiving appraisals within Medicaid managed care.Family caregiver support needs should be taken into account within policy and service assessments.

Organising healthcare services for persons with an intellectual disability

BACKGROUND

When compared to the general population, persons with an intellectual disability have lower life expectancy, higher morbidity, and more difficulty finding and obtaining healthcare. Organisational interventions are used to reconfigure the structure or delivery of healthcare services. This is the first update of the original review.

OBJECTIVES

To assess the effects of organisational interventions of healthcare services for the mental and physical health problems of persons with an intellectual disability.

SEARCH METHODS

For this update we searched CENTRAL, MEDLINE, EMBASE, CINAHL and other databases, from April 2006 to 4 September 2015. We checked reference lists of included studies and consulted experts in the field.

SELECTION CRITERIA

Randomised controlled trials of organisational interventions of healthcare services aimed at improving care of mental and physical health problems of adult persons with an intellectual disability.

DATA COLLECTION AND ANALYSIS

We employed standard methodological procedures as outlined in the Cochrane Handbook of Systematic Reviews of Interventions, in addition to specific guidance from the Cochrane Effective Practice and Organisation of Care (EPOC) Group.

MAIN RESULTS

We identified one new trial from the updated searches.Seven trials (347 participants) met the selection criteria. The interventions varied but had common components: interventions that increased the intensity and frequency of service delivery (4 trials, 200 participants), community-based specialist behaviour therapy (1 trial, 63 participants), and outreach treatment (1 trial, 50 participants). Another trial compared two active arms (traditional counselling and integrated intervention for bereavement, 34 participants).The included studies investigated interventions dealing with the mental health problems of persons with an intellectual disability; none focused on physical health problems. Four studies assessed the effect of organisational interventions on behavioural problems for persons with an intellectual disability, three assessed care giver burden, and three assessed the costs associated with the interventions. None of the included studies reported data on the effect of organisational interventions on adverse events. Most studies were assessed as having low risk of bias.It is uncertain whether interventions that increase the frequency and intensity of delivery or outreach treatment decrease behavioural problems for persons with an intellectual disability (two and one trials respectively, very low certainty evidence). Behavioural problems were slightly decreased by community-based specialist behavioural therapy (one trial, low certainty evidence). Increasing the frequency and intensity of service delivery probably makes little or no difference to care giver burden (MD 0.03, 95% CI -3.48 to 3.54, two trials, moderate certainty evidence). It is uncertain whether outreach treatment makes any difference for care giver burden (one trial, very low certainty evidence). There was very limited evidence regarding costs, with low to very low certainty evidence for the different interventions.

AUTHORS' CONCLUSIONS

There is very limited evidence on the organisation of healthcare services for persons with an intellectual disability. There are currently no well-designed studies focusing on organising the health services of persons with an intellectual disability and concurrent physical problems. There are very few studies of organisational interventions targeting mental health needs and the results of those that were found need corroboration. There is an urgent need for high-quality health services research to identify optimal health services for persons with an intellectual disability and concurrent physical problem.

Caregiving and Family Support Interventions: Crossing Networks of Aging and Developmental Disabilities

This scoping review addressed the following questions: (a) What types of caregiver interventions are being done in both aging and developmental disability research? (b) How are these interventions similar and different? (c) What kinds of outcomes do these interventions have? (d) What innovative approaches are these interventions using? and (e) What can each field (developmental disabilities and gerontology) learn from the other based on this review? The disability review spanned 20 years (1992-2012), resulting in 14 studies; the aging review spanned 5 years (2008-2012), resulting in 55 studies. Data from the final selected studies were then extracted and compared on research design, type of intervention (governmental programs, small-group psychosocial, and other), and outcomes. Generally, in both fields, family-support interventions benefited participants' well-being and improved service access and satisfaction. Increased partnership between the fields of aging and developmental disabilities is critical to future scholarship in caregiving for both populations.

Family well-being in a participant-directed autism waiver program: the role of relational coordination

BACKGROUND

Massachusetts is one of a very limited number of states exclusively employing participant-direction to deliver autism waiver services to children. A crucial element of this waiver program is the work conducted by the state's Department of Developmental Services (DDS) staff and state-approved providers with waiver families to facilitate the implementation of the participant-direction model. Our study investigates the effect of the collaboration between state providers and family caregivers on family well-being.

METHODS

We conducted a survey of 74 families who have been utilising waiver services for at least 6 months. Participants were asked to rate the coordination with providers as well as to report on parenting stress and impact of waiver services on family functioning. Data from in-home child and family assessments conducted by the state were also abstracted from program records.

RESULTS

After controlling for a host of variables hypothesised to affect the outcomes of interest, we found that the family's view of how well they coordinated with formal providers is significantly associated all of the outcomes. Families who reported greater coordination with state providers experienced lower parenting stress and reported a more positive impact on family functioning. Child externalising behavioural problems and caregiver's health rating also contributed to parenting stress and family functioning.

CONCLUSIONS

Our findings highlight the importance of establishing a collaborative partnership with waiver families in promoting family well-being. These results suggest that training and/or resources that foster team building and communication can positively impact family functioning among families with young children with autism.

Family caregivers of adults with intellectual and developmental disabilities: outcomes associated with U.S. services and supports

Individuals with intellectual and developmental disabilities (IDD) in the U.S. predominantly live with their family caregivers. As care delivery and support systems vary widely globally, consideration of caregiver outcomes specifically in the U.S. context is needed. A systematic literature review was conducted to identify U.S. family caregiver outcomes and their association with existing services and supports for family caregivers of adults with IDD. Twenty-four articles were compiled using the PubMed, Web of Knowledge, PsychInfo, and CINAHL databases. Studies report economic, mental, and physical health outcomes from caregiving roles. The need for comprehensive caregiver assessment is discussed. Understanding and responding to the changing needs of family caregivers is vital to the U.S. disability service system to effectively prioritize formal resources and services.

Identifying and Defining the Structures That Guide the Implementation of Participant Direction Programs and Support Program Participants

Participant direction (PD) programs offer the individual with a disability or his or her surrogate decision maker varying degrees of choice and control over the individual’s supports and services. We conducted a document analysis using grounded theory methods to identify the design elements of participant direction programs in long-term care. We analyzed 53 documents across multiple disabilities and funding sources. We identified and defined two major components of participant direction programs: policy and aid and assistance. The component of policy was represented by three structures that guide implementation of participant direction programs: (a) option to participant-direct, (b) participation stipulations, and (c) provider qualifications. The component of aid and assistance was represented by 11 structures that support program participants: (a) financial management services, (b) employer of record, (c) emergency back-up, (d) worker registry, (e) advice/counseling, (f) managerial assistance, (g) information dissemination products, (h) service quality monitoring, (i) service coordination, (j) participant training, and (k) provider training. Each structure was represented by one or more continua depicting the range of choice and control participants may have over the structure. The findings of this study have implications for improving the standardization of research on participant direction programs and the development of long-term care policy.

A social-ecological analysis of the self-determination literature

This paper uses a social-ecological lens to examine self-determination research, attempting to organize what is known (and unknown) about contextual factors that have the potential to impact the development and expression of self-determined behavior in people with disabilities across multiple ecological systems. Identifying and categorizing the contextual factors that researchers suggest influence self-determination have the potential to allow for the development of a framework that promotes systematic consideration of contextual factors when designing, implementing, and evaluating supports to promote self-determination. Directions for future research and practice are discussed.

Identifying and Defining the Activities of Participant Direction Programs

We analyzed the design of various U.S. programs of participant direction offering participants (individual with a disability or his or her surrogate decision-maker) some level of choice and control over the individual’s long-term care supports and services. We used grounded theory methods to conduct a document analysis of 53 documents published from 2004 through 2008 representing multiple disabilities and program funding sources. In our analysis, we identified three major components (planning, budgeting, and employing) over which participants had the opportunity to exercise choice and control and the activities associated with each. Activities were represented by one or more continua illustrating the range of participant choice and control over the indicator. The component of planning consisted of the activity of care plan development. The budgeting component included the activities of (a) development, (b) individualization, and (c) authority. The employing component included the activities of (a) identifying/selecting providers, (b) hiring/employing providers, (c) scheduling providers, (d) training providers, (e) managing/directing/supervising providers, (f) disciplining/dismissing providers, (g) keeping records, (h) managing payroll, (i) locating emergency back-up, and (j) monitoring service quality. The findings of this study have implications for improving policy, practice, and research in the field of long-term care.

End-users, Public Services, and Industrial Relations: The Restructuring of Social Services in Ontario

The global financial crisis beginning in 2008 resulted in a ballooning public debt and government efforts to constrain public expenditures. Responses to the financial crisis and its impact on human services in Ontario demonstrate the complex interactions across key actors – employers, government, unions, and family advocates. Building on previous scholarship which has explored the role of end-users as industrial relations actors (Bellemare, 2000; Kessler and Bach, 2011) this study deepens our understanding of the role and impact of end-users on the process and outcomes of industrial relations in the social services sector. The main contribution of the paper shows how end-users play unique and complex roles as industrial relations actors in Ontario’s developmental services sector. End-users have had a significant impact at three distinct levels of the industrial relations system (Bellemare, 2000). First, at the strategic level of public policy, in addition to the more traditional forms of grassroots lobbying, end-users have taken on formal roles in the governance network shaping public policy. The impacts of end-user advocacy have contributed to the significant transformation of the developmental services sector, including the closure of the remaining provincially-run institutions in 2009. Second, at the organizational level, end-users have displaced the traditional roles of employers. In some cases, this displacement has resulted in end-users operating as co-managers, with end-user management rights enshrined in collective agreements. In more significant ways, end-users have entirely replaced agency-based managers and become the employer of direct support staff. Third, end-users have driven changes at the level of the work process itself, going beyond the co-production of services, contributing to changes in the nature of direct support work. The work process has shifted from a focus on custodial care to more complex objectives of community development and social inclusion.

Self-directed support: impact of hiring practices on adults with intellectual and developmental disabilities and families

The study examined the differential experiences and outcomes for people with intellectual and developmental disabilities and their families receiving self-directed services based on the type of personal support worker hired (parents, siblings, other relatives, friends, and agency staff). The sample consisted of 372 participants in a self-directed waiver program who used personal assistance services. Results indicated that the caregiver's satisfaction with the personal support worker, self-efficacy in managing personal support workers, and mental health varied significantly based on type of personal support worker hired. Also, the physical health and daily choice making of the adults with disabilities differed significantly by type of personal support worker hired.

Maintaining Employment Among Caregivers of Individuals on a Medicaid Waitlist for Services

Many individuals with developmental or intellectual and other disabilities are on waitlists to receive supportive services through state Medicaid waiver programs. Being waitlisted can place considerable burden on the ability of a caregiver to maintain employment outside the home. This article reports on results of a survey of 442 caregivers of individuals waitlisted for services within the Florida Medicaid program. Logistic regression was used to model characteristics of caregiver and clients that are associated with the need for additional supports in order for the caregiver to maintain employment. Male caregivers and caregivers in fair or poor health were more likely to report needing support. Caregivers of clients who had behavior problems or problems with self-care were also more likely to need support to maintain employment. Policy responses to these findings include a call for increased supports or prioritization of services for caregivers who are in poor health or those who care for individuals with particularly problematic behaviors.

Examining the Experiences and Decisions of Parents/Guardians

Participant direction is a service delivery model in which the consumer of public benefits, or his or her surrogate decision maker, exercises some level of choice and control over the consumer’s supports and services. In this case study, the authors examined the decisions and experiences of parents/guardians who directed supports and services for an adult with significant intellectual and developmental disabilities (SIDD). Respondents included the parents/guardian of the adult as well as others in the circle of support identified by the parents/guardians. Data analysis revealed an overarching theme in which respondents perceived participant direction as a means to achieve an end, with the end being their desired outcomes for the adult with SIDD. Implications for policy include developing and providing supportive services to adults with SIDD and their parents/guardians due to the increased responsibilities associated with directing supports and services for the adult with a SIDD.

Doing nothing: adults with disabilities with no daily activities and their siblings

A significant concern of parents and professionals is that adults with intellectual and developmental disabilities will go without regular educational-vocational activities. The authors examined predictors of such inactivity in individuals with intellectual and developmental disabilities, as well as how inactivity related to their sibling's well-being and the sibling relationship. Participants included 796 siblings of adults with intellectual and developmental disabilities who responded to a web-based survey. Nearly 13% of adults with intellectual and developmental disabilities were without daytime activities; these adults had more emotional-behavioral and health problems, were more underserved by the formal service system, and had parents who were less able to provide care. Although siblings of adults without activities reported more depressive symptoms, worse health, and less close sibling relationships, inactivity no longer predicted these problems after controlling for characteristics that predisposed adults with intellectual and developmental disabilities to have no activities.

"It's our job": qualitative study of family responses to ableism

Forty-five parents of children with autism, cerebral palsy, Down syndrome, and sickle cell disease participated in 8 focus groups. Parents discussed how they, the child with the disability, and the siblings addressed community perceptions about the child's disability. Themes evolving from the interviews included (a) support and lack of support, (b) inclusion and exclusion, and (c) the family members' roles during their interactions with the community. Parents viewed their roles in the community as (a) advocating, (b) educating, (c) informing, (d) ignoring, and (e) hiding. The relationship between themes is presented, and the relationship between themes and parent empowerment is discussed as well as the ways in which the themes reflect underlying ableism.

Health and Access to Health Care of Female Family Caregivers of Adults With Developmental Disabilities

The physical and mental health status of women providing care to adult relatives with developmental disabilities was compared with that of the general female population in the United States. There were no differences on physical health across four age groups. However, the mental health of midlife caregivers (45—54 years of age) and older caregivers (older than 65 years) was worse than national norms. This may be associated with two key periods: transitions to adulthood of individuals with disabilities and transitions when aging caregivers are no longer able to provide care. Greater unmet needs for services contributed to poorer mental health. Poorer access to health care also contributed to poorer mental and physical health. Unmet needs for services and out-of-pocket disability-related expenses appeared to pose difficulties for working age caregivers in affording the financial costs of health care for themselves.

Family decision making: benefits to persons with developmental disabilities and their family members

Family involvement in planning and choosing services has become a key intervention concept in developmental disability services. This study (N = 547) modeled patterns of family decision making and assessed benefits to persons with developmental disabilities (DDs) and their family members. A latent profile analysis identified 4 classes that were highly involved in decision making (n = 118), involved only in planning (n = 166), involved only in financial decisions (n = 75), and uninvolved (n = 188). Multiple regression analysis indicated that consumers with DD whose family members were highly involved received more services than consumers in other families. A multivariate analysis of covariance indicated that the family members in the highly involved and planning classes experienced more family member satisfaction than others. Findings have implications for practice.

Longitudinal outcomes of a consumer-directed program supporting adults with developmental disabilities and their families

Longitudinal impacts of a consumer-directed support program that provides families with an individualized budget were studied at three points in time over a 9-year period: Time 1 (1991), Time 2 (1995), and Time 3 (2000). At Time 3, families in the program were also compared with families on the waiting list. Over time, families in the program experienced decreased unmet service needs, higher service satisfaction, increased community participation of individuals with disabilities, and decreased caregiver burden. At Time 3 families in the program had fewer unmet needs and higher service satisfaction than did families on the waiting list; there were no differences in community participation and caregiver burden.

Aging family caregivers: Policies and practices

This review examines later life family support for adults with developmental disabilities from a life course perspective that takes into account social trends and changes in service patterns and in attitudes of families. Key issues addressed include: (1) trends affecting family caregiving, (2) health and social outcomes of life-long caregiving, (3) support needs of families, (4) family support policies and practices, and (5) recommendations for a research and policy agenda. Research examining outcomes of life-long caregiving has shown that most families adapt well to having a family member with disabilities. However, some families are at risk for poorer physical and mental health outcomes. These include cultural minorities and families of adults with behavioral challenges. Caregiving does seem to have a negative impact on maternal employment and family income as mothers often give up or cut back on employment to care for a child with developmental disabilities, who is more likely to continue living in the family home throughout adulthood than other adult children. Federal and state initiatives are addressing issues of family support through both the developmental disabilities and aging service systems.