'Growing Old' in Shelters and 'On the Street': Experiences of Older Homeless People

Homelessness among older people in Canada is both a growing concern, and an emerging field of study. This article reports thematic results of qualitative interviews with 40 people aged 46 to 75, carried out as part of a mixed-methods study of older people who are homeless in Montreal, Quebec, Canada. Our participants included people with histories of homelessness (n = 14) and persons new to homelessness in later life (n = 26). Interviews focused on experiences at the intersections of aging and homelessness including social relationships, the challenges of living on the streets and in shelters in later life, and the future. This article outlines the 5 main themes that capture the experience of homelessness for our participants: age exacerbates worries; exclusion and isolation; managing significant challenges; shifting needs and realities; and resilience, strength, and hope. Together, these findings underscore the need for specific programs geared to the unique needs of older people who are homeless.

The Untold Story of Being Designated an Alternate Level of Care Patient

INTRODUCTION

Much of the research and policy reports on Alternate Level of Care (ALC) in Canada have focused on the impact ALC has on acute care services. To date, the experiences and opinions of those who must wait in hospital for alternate services have been largely absent from discussions.

METHOD

A qualitative study was conducted with patients and families designated as ALC in one urban and two rural hospitals in Atlantic Canada. Data were analyzed using content analysis.

RESULTS

Three themes emerged from the data: a perception of normalcy, being old but not sick and anticipating relocation to another facility.

CONCLUSIONS

ALC is an important issue for patients and their families. Policy directives aimed at addressing the causes and impacts of ALC, identification and provision of appropriate supportive care in the community and sensitivity to the impact of ALC for individuals designated as ALC are needed.

Impact of a fixed price system on the supply of institutional long-term care: a comparative study of Japanese and German metropolitan areas

BACKGROUND

The need for institutional long-term care is increasing as the population ages and the pool of informal care givers declines. Care services are often limited when funding is controlled publicly. Fees for Japanese institutional care are publicly fixed and supply is short, particularly in expensive metropolitan areas. Those insured by universal long-term care insurance (LTCI) are faced with geographically inequitable access. The aim of this study was to examine the impact of a fixed price system on the supply of institutional care in terms of equity.

METHODS

The data were derived from official statistics sources in both Japan and Germany, and a self-administered questionnaire was used in Japan in 2011. Cross-sectional multiple regression analyses were used to examine factors affecting bed supply of institutional/residential care in fixed price and free prices systems in Tokyo (Japan), and an individually-bargained price system in North Rhine-Westphalia (Germany). Variables relating to costs and needs were used to test hypotheses of cost-dependency and need-orientation of bed supply in each price system. Analyses were conducted using data both before and after the introduction of LTCI, and the results of each system were qualitatively compared.

RESULTS

Total supply of institutional care in Tokyo under fixed pricing was found to be cost-dependent regarding capital costs and scale economies, and negatively related to need. These relationships have however weakened in recent years, possibly caused by political interventions under LTCI. Supply of residential care in Tokyo under free pricing was need-oriented and cost-dependent only regarding scale economies. Supply in North Rhine-Westphalia under individually bargained pricing was cost-independent and not negatively related to need.

CONCLUSIONS

Findings suggest that publicly funded fixed prices have a negative impact on geographically equitable supply of institutional care. The contrasting results of the non-fixed-price systems for Japanese residential care and German institutional care provide further theoretical supports for this and indicate possible solutions against inequitable supply.

[Home care and place of death for elderly people living in the remote islands of Japan. An examination on the presence of inpatient facilities]

OBJECTIVES

The purpose of this study was to clarify the actual status of end-of-life care for elderly people living in the remote islands of Japan, and whether the presence of inpatient facilities was related to the place of death, so as to obtain suggestions for constructing a system of end-of-life care.

METHODS

The survey targeted caregivers (85 people) who cared for elderly people (aged 65 and over), who had been legally certified for long-term care, and who had died between April 2009 and July 2011 in five islands of Japan. Islands were selected from a list of remote islands specified in the Remote Islands Development Act and related laws. Using a mixed method embedded design, we conducted semi-structured interviews using a questionnaire that assessed the place and cause of the elderly patient's death, age at death, gender, and whether the patient or family members had requested that the patient be allowed to die at home.

RESULTS

The proportion of elderly people who died at home in the group living on remote islands with no inpatient facilities was 39.0% (16 of 41 people), compared with 18.2% (8 of 44 people) living on islands with inpatient facilities. The difference was significant (P=0.029). Among the 24 elderly people who died at home, 6 died of cancer. Terminally ill cancer patients were released to die at home under three conditions: the caregivers could provide sufficient care, the visiting physician was present, and pain control was provided. It was also possible for elderly cancer patients to receive end-of-life care in remote islands that did not have inpatient facilities. In addition, among the elderly people who died at home in the remote islands, home care had been recommended by medical staff.

CONCLUSION

It is important for professionals coordinating home care to understand the characteristics of diseases, perform early assessment of caregiver situations, and collaborate with medical staff.

Forced into exile: the traumatising impact of rural aged care service inaccessibility

INTRODUCTION

The shortage of residential aged care places is especially acute in rural areas and this results in many older people who live in these areas being forced to leave their home communities to access care in distant communities. This article reports on one aspect of a larger study that explored family and caring community members' experiences when someone they cared for needed to access residential aged care away from their rural communities.

METHODS

This qualitative research project, informed by phenomenology, was conducted in rural communities of New South Wales (NSW), Australia. Participants were recruited from media coverage of the proposed research. Indepth interviews were conducted, audiotaped and transcribed.<strong> </strong>Thematic analysis was undertaken by two researchers independently analysing the themes and then cross-checking these to ensure their strength.

RESULTS

The 21 interviews conducted revealed that inaccessibility of residential aged care places caused many to experience loss, loneliness and a sense of social disconnectedness. The affected rural older person is exiled from their home community only to return to be buried. There are implications for the family and the rural community who are distanced by kilometres, transport and finances and, more significantly, by the emotional ties that bind families, friends and communities.

CONCLUSION

The participants whose experiences were explored in this article described a sense of being in exile when residential aged care services are inaccessible in their local communities. The sense of exile is felt not only by the person moving away but also by their family, friends and neighbours. For this reason, rural residential aged care service delivery should be based on the identified needs of the older person and those who love and care for them.

Care for people with dementia in Slovenia

The number of patients with dementia in Slovenia will increase 33% in the next ten years. Unfortunately, networks offering different activities for demented patients are still insufficiently developed, although in the last ten years a significant improvement has been observed in all areas of care (diagnosis, treatment, day care centres, nursing homes, and non-governmental organizations). The article provides a short overview of developing care for persons with dementia in Slovenia.

Study of American and Chinese family members' evaluations on institutionalized care for their older parents: potential development in the future

The evaluations on institutionalized care facilities from family members, after their loved ones moved into such services, are very different from culture to culture, family to family and person to person. According to a recent survey in the United States and China, it is found that different cultures and the different health conditions of the residents strongly influence family member's viewpoints on institutionalized care services. It is also found that the availability of the institutionalized care facilities plays a significant role, which strongly affects family members' evaluations on nursing home services.

An aged persons mental health service in remote Victoria

OBJECTIVE

To describe an aged persons mental health service in the Sunraysia district in remote Victoria.

CONCLUSION

The aged persons mental health community team undertakes the bulk of the service's work. The data for 2 years are presented and demonstrate how effective the team is. Good relationships and linkages have been built with the local hospital, general practitioners, aged residential care services and the local aged care assessment service. During the 2 year period, very few elderly patients were admitted to the inpatient psychiatric facility and patients suffering from dementia were rarely admitted.

Transfer of patients from acute to long-term care: influence of patient characteristics on waiting period

Hawaii's number of nursing home beds per capita is much lower than the national average, making it difficult to transfer some hospitalized patients to long-term care facilities. We prospectively followed patients wait-listed for nursing home placement in two Honolulu hospitals and found several patient characteristics that impeded transfer. These results could be used to help with long-term care planning.

Evaluation of the age-adjusted incidence of hip fractures between urban and rural areas: the difference is not related to the prevalence of institutions for the elderly

As many as 40% of hip fractures occur in institutions for the elderly. Several studies have demonstrated a higher age-adjusted incidence of hip fractures in urban areas compared with rural areas. To assess whether this difference could be due to a preferential location of institutions for the elderly in urban areas, we compared the incidence of hip fractures over a 5-year period in urban versus rural areas, as defined according to the population density (urban > 15 inhabitants/ha2). We then determined the age-adjusted incidence of hip fractures in institutional-dwelling elderly and home-dwelling elderly. Hip fracture incidence was 100.0/100,000 (150.5 in women and 43.8 in men) in urban areas, and 71.0/100,000 (107.2 in women and 32.8 in men) in rural areas (p<0.001). When only those patients living in their own homes were analyzed, the incidence was 66.7/100000 (94.6 in women and 35.7 in men) in urban regions and 36.8/100,000 (49.6 in women and 23.4 in men) in rural areas (p<0.001), a difference of even greater magnitude than when both home-dwelling and institutional-dwelling residents were considered together. In a logistic regression model including age class, gender, urban or rural areas and institutionalization for inhabitants 65 years of age and older, urban residents have a 31% significantly (p<0.001) higher incidence of hip fracture compared with rural residents; women have a 79% significantly (p<0.001) higher incidence of hip fracture compared with men; and institutional-dwelling elderly have a 351% significantly (p<0.001) higher incidence of hip fracture compared with home-dwelling elderly. These results confirm the existence of a higher age-adjusted incidence of hip fractures in urban compared with rural areas. Since this difference is increased when patients living at home were analyzed separately, it indicates that the difference between urban and rural areas is not due to a preferential urban location of institutions for the elderly.

Specialized dementia programs in residential care settings

The authors conducted a telephone survey in 7 states to determine the prevalence of residential care specialized dementia programs (RC-SDPs) and to identify a sample of homes (n = 56) for more detailed study. The 56 homes were site visited, and data were gathered on facility administration, therapeutic environment, and characteristics of 259 randomly selected residents. Comparison data from 138 nursing home Special Care Units (NH-SCUs) and 1,340 of their residents were obtained from 4 studies conducted in the same 7 states. RC-SDPs were smaller, provided a more homelike environment, and had a higher proportion of residents paying privately, compared with NH-SCUs. Mean levels of cognitive and physical impairment among residents were higher in NH-SCUs; prevalences of psychotropic medication use and problem behaviors were similar. Among RC facilities, small homes were more homelike, provided fewer structured activities, and charged less than larger facilities. RC-SDPs include 5 types: small, independently operated homes; multiple small homes with joint administration; larger, all-dementia facilities; SDPs operated within larger, exclusively RC facilities; and RC-SDPs in multilevel facilities.

[Housing policy and aging--staying as long as possible in personal housing?]

Housing elderly residents is a major concern in all European countries. The topic of this article is the development of a new preventive approach to housing older people in Denmark based on a comparative analysis of elderly people's needs and wishes to housing in old age carried out in 1996-97 for the Danish Council on Housing of the Elderly. The former well-established slogan "stay in your home as long as possible" will gradually be replaced by the new slogan "Move in time, while you can--and before others decide for you". About one-fifth of the present 60-year olds are looking for another living environment for ageing. This calls for a diversity in housing provision. A preventive policy should take into account a much needed mobility within the housing sector, the reduction of public expenditure by providing adequate housing suited for persons with disability and the rapid increase in the number of seniors who will in 15 years' time demand that their needs and wishes should be met.

[Regional disparities in accessibility of inpatient treatment for elderly patients]

This article analyzes the supply of residential care facilities for old people in Germany with the aim to discover regional disparities. The analysis is based on the directory of residential institutions for old people (Altenheimadressbuch). On a national level the supply of residential care facilities in this data base is comparable with the results of the national statistic (Heimplatzstatistik). The results show considerable disparities that only to a minor extent coincide with the regional distribution of older people. Although there is no definite coherence between the supply of residential care facilities and the family care potential, there is a significant negative correlation between both.

The changing availability of residential aged care in Australia

Australian aged care services have undergone a series of substantial reforms in recent years under the rubric of the Aged Care Reform Strategy. Overall, there has been a progressive refinement of the targeting of available services on those most in need, defined in terms of both disability levels and financial resources. A key component of this process has been a deliberate reduction in the relative emphasis accorded to nursing home care within the aged care system. This has been accompanied by increases in the resources directed toward less intensive forms of residential care (hostels) and community based services. This paper explores the actual consequences of these intentional policy changes in terms of the availability of nursing home and hostel care, and the changing characteristics of nursing home residents. The results suggest that a more substantial reduction has occurred in the availability of nursing home care than has hitherto been suggested, with consequent decreases in the proportion of aged persons in nursing homes. The effect has been particularly marked amongst women and the very old. These findings raise policy questions about the appropriateness of current and planned future levels of provision.

The social context of Hong Kong's booming elderly home industry

Hong Kong experienced a rapid increase in private homes for elderly people in recent years. This paper examines the social background of that development. Private elderly homes thrived in a context of rising demand due to changing demographics, particularly massive emigration secondary to political instability, which created a large potential market of elderly people in need of residential care. However, entrepreneurs would not be attracted unless it is a profitable business, and much of that profit is likely derived from social security payments to elderly people. Because the amount of social security benefits is way below the level required for purchasing good quality service in the private sector, many elderly people are bound to ive in very poor residential settings.

Waiting times for nursing-home placement: the impact of patients' choices

OBJECTIVE

To identify patient characteristics and characteristics of long-term care facilities that significantly affect the waiting time for transfer from hospital to nursing home.

DESIGN

Cohort study.

PARTICIPANTS

All patients designated to be transferred from four Winnipeg hospitals between June 1, 1988, and May 31, 1989. The patients were followed up until placement, death or May 31, 1990.

MAIN OUTCOME MEASURE

Length of time waiting for nursing-home placement and relative rates of placement.

RESULTS

The variable found to shorten the waiting time the most was the patient's choice of a for-profit or nonprofit secular facility; other significant variables were male sex, age of 75 to 84 years and occupancy of an acute care bed during the wait.

CONCLUSION

The province has three policy options: it can increase the proportion of secular nursing-home beds when new facilities are built; it can require that hospital patients accept an interim nursing-home placement pending transfer to the nursing home of their choice; or it can tie the sponsorship of new facilities to a formula based on the ethnoreligious distribution of the population currently aged 55 to 64 years.

[Policy on the aged of the Federal government in the 12th legislative period]

Social policy for the elderly requires an analysis of the older generation's living conditions in the Federal Republic of Germany. Personal competence has to be maintained in order to prevent the need for nursing care. The urgent problems resulting from demographic changes in the population structure are met by societal and political institutions.

Boom in rest homes in Auckland: implications for the future

Available beds for frail elderly people in the rest home sector in Auckland increased from 44 to 67 per 1000 population over 65 years between 1981 and 1988. This expansion is partly explained by the financial incentives provided by various government subsidies including an open-ended number of rest home subsidies available subject only to an assessment by a geriatric team and a means and assets test. Four estimates of the number of beds required in the Auckland region for the year 2001 indicate that as few as 3414 beds or as many as 7450 beds will be required depending on the assumptions used. The best estimate suggests that approximately 5200 beds are required for the population 65 years and over in the year 2001, 800 fewer than the 6000 currently available. This estimate does not include an allowance for the provision of care for people less than 65 years of age, nor for a proportion of beds to remain vacant and nor for seasonal fluctuations in the demand for rest home beds. These projections have important policy implications for the future funding and provision of rest home care.

The decision process for retirement center development: is market research being used effectively?

This paper examines the role of market research in the decision process used to invest in continuing care retirement centers (CCRCs). Given changing demographics and the availability of financing, there has been a rapid increase in the number of CCRCs that are being developed. However, a large number of these centers have either failed or are experiencing financial difficulty. Some industry participants have blamed poor or inadequate market research as a factor contributing to the failure of many centers to meet expectations. This paper discusses how the process used to invest in centers and how the motivations of the different actors in the investment decision can influence the role and use of market research. Recommendations are suggested for how industry investors can better understand and use market research in the decision to invest in a retirement center.

Analysis of nursing home use and bed supply: Wisconsin, 1983

This article presents evidence that in 1983 excess demand was a prevailing characteristic of nursing home care markets in Wisconsin, a state with one of the highest bed to elderly population ratios. It further shows that excess demand is the source of at least three types of error in use-based estimates of the determinants of the need for nursing home care. First, if excess demand is present, estimates of the determinants of Medicaid use may simply represent a crowding out of Medicaid patients, driven by the determinants of private use. As a result, factors associated with greater overall need in an area will be correlated with fewer Medicaid patients in nursing homes, ceteris paribus. Second, estimates of the substitutability of home health care for nursing home care may be misleadingly insignificant if they are based on the bed supply-constrained behavior of Medicaid-eligible subjects. Third, because the determinants of bed supply become the determinants of overall use under excess-demand conditions, the determinants of use will reflect, to some extent, the nursing home's desire for profits. Because profitability considerations are reflected in use based estimates of need, these estimates are likely to be misleading.

[Local backgrounds of demand and supply of nursing homes]

This report deals with the question, why municipalities differ so much in the number of elderly who are staying in a home for the aged. Official statistics, the national survey in 1982 and a local survey among the elderly in a municipality with a low capacity have been analysed. Some interesting results of the report are: if there isn't a home for the elderly in the domicile -- and the elderly have to move to another village for the care they need -- many prefer to stay on their own. In the past alternatives (such as special dwellings, more home help, etc.) have been created. In municipalities with many small villages also a relatively low capacity of homes for the elderly has been realised in the past. An other determinant of the capacity is the political and religious structure of a municipality.