Successful Discharge of Short Stay Veterans from VA Community Living Centers.

The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.

Barriers to a Timely Discharge From Short-Term Care in VA Community Living Centers.

This study aimed to identify the barriers to a timely discharge from short-term care in Veterans Health Administration (VHA) Community Living Centers (CLCs). Ninety-nine interviews were conducted with CLC staff in leadership and direct-care positions in eight varied CLCs. Major themes identified through qualitative analysis as barriers to a timely discharge were a lack of patients' financial resources, low social support, and reluctance of some veterans and staff to view a timely veteran discharge as their goal. Staff also perceived that barriers were much more difficult to overcome in regions where community-based long-term services and supports were limited or nonexistent. Because VHA has lagged behind Medicaid more generally in terms of investment in these types of services, additional strategies are warranted to achieve the important policy goal of deinstitutionalizing VHA care and returning veterans to their homes in the community.

Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community.

The United States Department of Veterans Affairs (VA) is facing pressures to rebalance its long-term care system. Using VA administrative data from 2004-2011, we describe changes in the VA's nursing homes (called Community Living Centers [CLCs]) following enactment of directives intended to shift CLCs' focus from providing long-term custodial care to short-term rehabilitative and post-acute care, with safe and timely discharge to the community. However, a concurrent VA hospice and palliative care expansion resulted in an increase in hospice stays, the most notable change in type of stay during this time period. Nevertheless, outcomes for Veterans with non-hospice short and long stays, such as successful discharge to the community, improved. We discuss the implications of our results for simultaneous implementation of two initiatives in VA CLCs.

An Unintended Consequence of Culture Change in VA Community Living Centers.

OBJECTIVE: Although a growing body of evidence suggests that culture change and its corollary, person-centered care improves resident outcomes in the nursing home setting, little is known about the effect of culture change in a postacute setting in which patients receive skilled nursing and rehabilitation services for a relatively short period of time before returning home. DESIGN: Data for this study were collected as part of a larger project to understand the impact of Veterans Health Administration (VHA) policies to shift the mission of VHA Community Living Centers (CLCs) from long-stay custodial care to short-stay skilled nursing and rehabilitative care. RESULTS: Although qualitative data collected during interviews from site visits to eight geographically diverse CLCs suggest an increase in the quality of life and care for veterans, interview data also indicate an unintended consequence. Specifically, staff described how aspects of the homelike environment, relationship-based care delivery, and attention to veterans' preferences that characterize culture change can prolong a veteran's length of stay beyond treatment completion. In addition to providing skilled nursing and rehabilitation, VHA CLCs also serve a latent function of providing a comfortable home and a peer community for veterans to connect and socialize with one another. A congregate living environment for persons with the shared symbolic status of being a veteran is unique to VHA CLCs. Strong bonding among peers and staff as well as staff respect for veterans' service to the country may increase their sense of obligation to keep veterans past their expected discharge date. CONCLUSION: Our findings suggest that the complexities of culture change and veteran- centered care in a short-term care setting may be underrecognized. We discuss how findings may also be relevant for the non-VHA sector.

Interagency partnership to deliver Veteran-Directed Home and Community-Based Services: Interviews with Aging and Disability Network agency personnel regarding their experience with partner Department of Veterans Affairs medical centers.

Veteran-Directed Home and Community-Based Services (VD-HCBS) is a consumer-directed program that began in 2009 and is jointly administered in a partnership between the Veterans Health Administration and the Administration for Community Living. The objective of this article is to describe the Aging and Disability Network agency (ADNA) personnel's perceptions of the implementation of the VD-HCBS program with partner Department of Veterans Affairs medical centers (VAMCs). Qualitative interviews with 26 ADNA VD-HCBS personnel across the country were transcribed, coded, and analyzed. Results suggest that the majority of ADNA personnel interviewed perceive the collaboration experience to be positive. Interviewees reported several key mechanisms for facilitating a successful partnership, including frequent communication, training in VAMC billing procedures, having a designated VAMC staff person for the program, and active involvement of the VAMC from the onset of VD-HCBS program development. Findings have implications for other interagency partnerships formed to deliver services to vulnerable Veterans.

Variation in the Presence of Simple Home Modifications of Older Americans: Findings from the National Health and Aging Trends Study.

OBJECTIVES: To investigate the association between sociodemographic and economic factors and the presence of simple home modifications (HMs) among older adults in the United States. DESIGN: Cross-sectional. SETTING: National Health and Aging Trends Study (2011, Round 1). PARTICIPANTS: Community-dwelling Medicare enrollees aged 65 and older (N = 6,628). MEASUREMENTS: The primary dependent variable was the reported presence or absence of simple HMs (grab bars in the shower or near the toilet, shower seats, raised toilet seats). RESULTS: Of the individuals sampled, 60.7% reported having at least one HM of interest. Black (odds ratio (OR) = 0.79, 95% confidence interval (CI) = 0.68-0.91) and Hispanic (OR = 0.60, 95% CI = 0.45-0.78) respondents were less likely than white, non-Hispanic respondents to have HMs. Those with more education (high school graduate: OR = 1.20, 95% CI = 1.01-1.42; >high school: OR = 1.36, 95% CI = 1.14-1.62) and larger social networks (≥4 people; OR = 1.46, 95% CI = 1.12-1.89) were more likely to have at least one HM, whereas being divorced (OR = 0.57, 95% CI = 0.43-0.74) was associated with lower likelihood. Income (OR = 1.01, 95% CI = 0.97-1.05), Medicaid enrollment (OR = 0.98, 95% CI = 0.77-1.25), and living alone (OR = 1.02, 95% CI = 0.85-1.23) were not significantly associated with the presence of HMs. CONCLUSION: Minorities, individuals with less education, and those with less social support are less likely to have HMs. Awareness of these disparities and the shortcomings of the HM delivery system is important to clinicians and policy-makers who seek to prevent falls and facilitate aging in place for all older Americans.

Functional limitations as potential mediators of the effects of self-reported vision status on fall risk of older adults.

OBJECTIVE: To test whether limitations in mobility and large-muscle functioning mediate self-reported vision status to increase fall risk among respondents age 65 and above. METHOD: This study used two waves from the Health and Retirement Study. We conducted binary logistic and negative binomial regression analyses to test indirect paths leading from self-reported vision status to falls, via indices of mobility and large-muscle functioning. RESULTS: Limited evidence was found for a mediating effect among women; however, large-muscle groups were implicated as partially mediating risk factors for falls among men with fair self-reported vision status. DISCUSSION: Implications of these findings are discussed including the need for prioritizing improved muscle strength of older men and women with poor vision as a preventive measure against falls.

The adverse consequences of unmet need among older persons living in the community: dual-eligible versus Medicare-only beneficiaries.

OBJECTIVE: Our objective is to estimate and compare the prevalence of selected adverse consequences associated with unmet need for assistance among a socioeconomically and medically vulnerable subgroup of the older adult population, those who are dually eligible for Medicare and Medicaid, with those eligible for Medicare only. METHOD: Using data from the National Health and Aging Trends Study (NHATS), a representative survey of the older Medicare population, we calculated the prevalence of disability-related need for assistance with self-care, household tasks, and mobility activities and the prevalence of adverse consequences of unmet need by dually eligible and Medicare only status. RESULTS: Over 2 million community-dwelling older persons experienced an adverse consequence due to unmet need for assistance with self-care (e.g., soiled their clothes), over 2 million experienced adverse consequences due to unmet need for assistance with household tasks (e.g., went without groceries), and over 3 million persons experienced at least one adverse consequence of unmet need for assistance with mobility-related activities (e.g., had to stay in bed) in the month prior to the NHATS interview. Dually eligible persons experienced higher rates of 6 of the 11 adverse consequences studied and were more likely to have at least one adverse consequence in all 3 domains than others. DISCUSSION: Several care models are emerging with the goal of integrating medical care, behavioral health, and long-term services for the dual eligible population. Indicators of adverse consequences of unmet need could be used to monitor the quality and adequacy of such care systems.

Primary caregiver characteristics and transitions in community-based care.

OBJECTIVES: To identify informal primary caregiver characteristics associated with care transitions of community-dwelling older persons with impairments in daily living activities. METHOD: Data for this study were pooled to observe transitions from Wave 1-Wave 2 and Wave 2-Wave 3 of the Second Longitudinal Survey on Aging (LSOA II). The sample includes respondents with at least one impairment in daily living activities and with an informal caregiver at baseline of each transition period (n = 2,990). Primary caregiver transitions to another informal caregiver, to formal care, to a nursing home, or to no care were modeled using multinomial logistic regression. RESULTS: More than half (54%) of the surviving respondents experienced a care transition for a period of 2 years. Multivariate results indicate that husband and son primary caregivers are more likely to transfer care than wives and daughters, although children caring for same-gender parents were less likely to transfer out of the primary caregiver role than children caring for parents of the opposite sex. Respondents with primary caregivers who are "other" relatives or nonrelatives, who are not coresident with the care receiver, or who are assisted by secondary helpers were at elevated risk for care transitions over the 2-year study period. DISCUSSION: The results of this study suggest that older persons' care transitions result from complex informal network dynamics, with primary caregiver gender and relationship to the care receiver playing key roles.

Oncologists' confidence in knowledge of fertility issues for young women with cancer.

We sought to identify factors associated with greater cancer-related fertility knowledge in a national survey of oncologists. We surveyed 344 oncologists from a sampling pool drawn randomly from the AMA Masterfile. We conducted multiple linear regression to determine the relationship between confidence in knowledge and oncologists' characteristics. Respondents' average age was 48.5, and 75.3% were male. The average confidence in knowledge summary score was 23.8 (SD 6.4, range 8-40). In multivariable regression, confidence was higher among oncologists with more information resources, a sense of responsibility to discuss fertility issues and among gynecologic oncologists vs. other oncology specialties. Physician age, gender, and practice setting were not associated with fertility-related knowledge. Oncologists lack confidence in their knowledge of fertility issues in young women with breast cancer. Increasing professional responsibility to discuss fertility and greater information access could improve the depth and breadth of education regarding fertility issues among oncologists and their young patients.

Self-reported vision impairment and its contribution to disability among older adults.

OBJECTIVE: To examine contributions of self-reported vision impairment to disability by persons 65 years and older. METHOD: We used data from the National Health and Nutrition Examination Survey (NHANES IV; 1999-2008; weighted N = 6,550). The four-staged Nagi model of the disability process, incorporating biomarkers, disease, and physical functioning, was used as a framework to guide variable selection. An unadjusted ordinal logistic regression model testing effects of vision on daily-life activities was compared with models that controlled covariates associated with each stage of the disability model. RESULTS: Where significant effects of poor vision remained, the strongest effect was found for doing leisure activities at home (OR = 5.29; 95% CI [3.14, 8.90]). DISCUSSION: Results suggest the importance of considering multiple health factors when formulating comprehensive vision rehabilitation interventions.

Conducting telephone interviews with community-dwelling older adults in a state Medicaid program: differences by ethnicity and language preference.

We document the methodological challenges of conducting a health survey of an ethnically diverse elderly community-dwelling Medicaid population by telephone. Individuals (N=5,382) 65 years and older were randomly selected from a state Medicaid Management Information System and 618 eligible participants were interviewed. Participants were classified as non-Hispanic White, English-speaking (NHW-E; 69.2%), non-Hispanic Black, English-speaking (NHB-E; 6.2%), Hispanic, Spanish-speaking (H-S; 9.2%), and Hispanic, English-speaking (H-E; 4.2%). Almost half (44.2%) of the individuals sampled were unreachable, most often because of no valid telephone number. More interviewer time was required to reach and interview Hispanic participants. On average, interviews with H-S and H-E were 11 and 8 minutes longer, respectively, than with NHW-E. Spanish-speaking Hispanic respondents reported very high rates of receipt of preventive services relative to the other groups. These high rates by Spanish-speakers may be due to actual greater utilization or biases in self-reported data due to response style differences.

Subjective burden and personal gains among older parents of adults with serious mental illness.

OBJECTIVE: Whereas many studies have examined the long-term toll of coping with an adult child's serious mental illness, relatively few have examined both the subjective burden and personal gains associated with this parenting role. This study investigated the stressors and resources related to burden and gains among older parents of adults with serious mental illness. METHODS: The study was a secondary analysis of data collected in the Wisconsin Longitudinal Study. Regression analysis of telephone and mailed responses of 111 parents of adults with serious mental illness was used to examine the stressors and resources associated with parental burden and gains. RESULTS: Stressors that were positively associated with subjective burden included the amount of care provided to a child with serious mental illness; parents and children living in the same household was also positively associated, although it was not statistically significant (p=.07). Parents who received more assistance from an adult child with serious mental illness and those who were support group members reported less subjective burden and more gains. A higher number of confidants were also positively associated with gains. Parents who provided more assistance with activities of daily living to their adult child reported higher levels of gains. CONCLUSIONS: Findings suggest that recovery-oriented approaches to supporting families in later stages of life may involve creating opportunities for adults with serious mental illness to play positive roles in the lives of aging parents and in helping older parents recognize ways in which successfully coping with caregiving challenges may lead to personal gains.

Exploring physical activity behaviour of persons with multiple sclerosis: a qualitative pilot study.

PURPOSE: Identify facilitators and barriers to physical activity (PA), and explore the utility of Social Cognitive Theory (SCT) and Transactional Model of Stress and Coping (TMSC) in understanding PA behaviour among persons with multiple sclerosis (MS). METHODS: Thirteen participants from a clinical trial were interviewed and classified as physically active, sometimes active or inactive based on the Health-Promoting Lifestyle Profile-II. Interviews were analysed using analytical induction, which consisted of coding data into pre-established categories and then exploring similarities and differences between groups. Pre-established coding categories were constructs from SCT (i.e. environment, expectations, self-efficacy and self-regulation) and TMSC (i.e. stress appraisal and coping style). RESULTS: Inactive and active participants differed in their self-regulation skills, self-efficacy and coping styles. Common barriers to PA included symptoms and the physical and social environment. Facilitators of PA included strong self-regulation skills, confidence to overcome symptoms to engage in PA (i.e. barrier self-efficacy) and positive coping styles. CONCLUSION: Results from this pilot study suggest that PA interventions will need to implement multiple strategies that target self-efficacy, social environment and coping styles. We found SCT and TMSC useful in understanding PA behaviour among persons with MS; however, a limitation to these theories is that they are not explicit in the relationship between health and cognitions. Future research will need to explore how to incorporate models of health and function into existing behaviour change theories.

Commentary: navigating the labyrinth of long-term care: shoring up informal caregiving in a home- and community-based world.

Informal caregivers face difficulties navigating the services and funding sources that constitute long-term care. Indeed, barriers to identifying and accessing even the most basic resources compound the sense of isolation felt by millions of unpaid individuals who provide the bulk of long-term care. Though expansion of home- and community-based options is welcomed, it may also shift additional caregiving burden onto an already overburdened informal care system, especially when the intention is to delay or substitute for institutional care. This essay argues that growing government emphasis on rebalancing long-term care away from nursing homes will founder unless public officials recognize increased burdens on the informal care system.

Continuity in provider and site of care and preventive services receipt in an adult Medicaid population with physical disabilities.

BACKGROUND: This study investigated the relationship between continuity of care (having one's own doctor and a regular site of care), and receipt of preventive services in a population of adult fee-for-service Medicaid enrollees with physical disabilities. METHODS: A random sample of 555 physically disabled Rhode Island Medicaid enrollees aged 18 to 64 years were surveyed by telephone. Respondents were asked about receipt of six preventive services in the previous year. They were also asked whether they had their own doctor and whether they had a regular site of care. Regression analyses with propensity score corrections for selection bias were used to test the associations between care continuity measures and the number of preventive services received, as well as the receipt of each individual service. RESULTS: After adjustment for predisposing, enabling, and need factors, respondents with their own doctor received 0.73 more preventive services than peers without their own doctor, and respondents who had a usual site of care received 0.85 more services than peers who received care at the emergency department or who had no regular site. The influences of having a regular doctor and a usual site of care varied according to type of preventive service, and these influences appear to be largely complementary rather than overlapping. CONCLUSIONS: Study findings suggest that care models for adults with physical disabilities should include mechanisms to ensure both physician and site continuity. A strong primary care component that links individual patients with a personal doctor, as well as care protocols that ensure receipt of preventive services, appear to be optimal for medically needy populations.

Spousal caregiving in late midlife versus older ages: implications of work and family obligations.

OBJECTIVES: This study examined life-stage differences in the provision of care to spouses with functional impairment. METHODS: We examined 1,218 married adults aged 52 and older from the 2000 wave of the Health and Retirement Study who received impairment-related help with at least one activity of daily living. We examined the differential likelihood that spouses served as primary caregiver and the hours of care provided by spousal primary caregivers by life stage. RESULTS: We found that late middle-aged care recipients were more likely than their older counterparts to receive the majority of their care from their spouse but received fewer hours of spousal care, mostly when spouses worked full time. Competing demands of caring for children or parents did not affect the amount of care provided by a spouse. DISCUSSION: Late middle-aged adults with functional limitations are more likely than older groups to be married and cared for primarily by spouses; however, they may be particularly vulnerable to unmet need for care. As the baby boom generation ages, retirement ages increase, and federal safety nets weaken, people with health problems at older ages may soon find themselves in the same caregiving predicament as those in late middle age.

Using International Classification of Functioning, Disability and Health to understand challenges in community reintegration of injured veterans.

This pilot study used the framework of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) to understand the challenges faced by Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans as they reintegrate into the community. We conducted semistructured interviews with 14 injured veterans, 12 caregivers, and 14 clinicians. We used ICF taxonomy to code data and identify issues. We identified challenges in the following ICF domains: learning and applying knowledge; general tasks and demands; communication; mobility; self-care; domestic life; interpersonal interactions, major life areas; and community, social, and civic life. We found many similarities between the challenges faced by veterans with and without polytraumatic injuries, although veterans with polytraumatic injuries faced challenges of greater magnitude. Identifying community reintegration challenges early and promoting reintegration are important mandates for the Department of Veterans Affairs. The findings of this study are useful in understanding the needs of OEF/OIF veterans.

Obesity and receipt of personal care assistance for people with mobility impairments.

OBJECTIVE: The purpose of this study was to evaluate the extent to which level of obesity was associated with hours of personal care among people with mobility impairments. RESEARCH METHODS AND PROCEDURES: The analytic sample consisted of 9496 respondents to the Adult Disability Follow-Back Survey (NHIS-D Phase II) who had mobility difficulty and difficulty with at least one activity of daily living or instrumental activity of daily living. Logistic regression analyses determined the relationship between level of obesity and receipt of any paid or unpaid help, controlling for potential confounders. In addition, differences in hours of help by level of obesity were evaluated using multiple regression. RESULTS: In the crude analysis, obese respondents were significantly less likely to receive any paid help than normal weight respondents (average odds ratio 0.75) and received significantly fewer hours of both paid and unpaid help. The difference in prevalence of receipt of any unpaid and any paid help by level of obesity was explained by adjustment for age and other demographic characteristics. Adjusted hours of paid and unpaid help were equivalent for those with and without obesity. DISCUSSION: Obese people with mobility impairments received less help with personal care than those of normal weight, although these findings are explained by demographics. Nevertheless, these findings raise public health concerns given the growing obesity epidemic in the United States and lack of available resources to support younger persons with disabilities.

Disability as a "family affair": parental disability and childhood immunization.

BACKGROUND: There is a substantial body of research focusing on the health and healthcare utilization of individuals with a disability but less has been done to examine the impact of disability on nondisabled family members. OBJECTIVE: We sought to investigate the influence of parental disability on children's healthcare as measured by the timely receipt of childhood immunizations. RESEARCH DESIGN: Observations on 11,997 children between the ages 2 and 5 years were obtained from the 1994 and 1995 United States National Health Interview Surveys representing 27,534,841 children when weighted. Children are determined to be in compliance with the Centers for Disease Control immunization protocol at age 24 months if they have received 4 DTP, 3 polio, and 1 MMR vaccine dose. Disability is characterized using the activity and personal care scales from the National Health Interview Surveys. The data were analyzed using logistic regression controlling for factors identified in prior research to be related to timely receipt of immunization. RESULTS: Children living with a parent who is unable to provide his or her own personal care are 65% less likely (odds ratio = 0.35; 95% confidence interval = 0.17-0.70) to be immunized on time than children who live with parent(s) who do not have a disability. Children of parents who are limited in their personal care, and children of parents who have work limitations, are not less likely than children of nondisabled parents to receive immunizations on time. CONCLUSIONS: The impact of a parent's severe disability extends to the health care of dependent children. These findings argue for research to investigate the full scope of the effects of parental disability on children's health and for policies that address this impact.