A limited entitlement for community care: how members use services.

The goal of this paper is to show how members of three Social HMOs use a limited entitlement for community-based long-term care to meet their needs and solve their problems. The paper is based on in-home interviews with 48 aged Medicare beneficiaries who joined Social HMOs and are eligible for the entitlement. Members' experiences with case management (called service coordination), benefits for covered services, and cost-sharing requirements are explored. Members (and their informal caregivers) are found to have complex lives, into which community care fits (or does not fit) in varied ways, depending on preferences, experiences with providers, informal care, financial resources, and other factors. The paper provides insights into what kinds of problems people want to solve and how community care systems can be better designed to empower service users to solve them.

Depressive symptoms and cigarette smoking among teens.

CONTEXT: Although several risk factors for tobacco use have been implicated in the development of depression, smoking progression has typically been viewed as a consequence of depression. The results of limited longitudinal studies are controversial. OBJECTIVE: To assess the nature and direction of the relationship between cigarette smoking and depression among teens. DESIGN: Prospective analysis of baseline and 1-year follow-up data from the National Longitudinal Study of Adolescent Health. SETTING: In-home teen and parent interviews. PARTICIPANTS: Two samples were identified. For the first sample, 8704 adolescents who were not depressed at baseline based on CES-D scores were identified for analyses of the effects of cigarette smoking on development of high depressive symptomatology. Baseline smoking status, which could vary in this group, was the predictor of interest in these analyses. For the second sample, 6947 teens who had not smoked cigarettes in the 30 days before the baseline survey (noncurrent smokers) were identified for analyses on the effect of high depressive symptoms on subsequent moderate to heavy cigarette use at 1 year of follow-up. Baseline high depressive symptomatology based on CES-D score was the predictor of interest in this sample. MAIN OUTCOME MEASURES: Among the nondepressed, developing high depressive symptoms at 1 year of follow-up. Among noncurrent smokers, smoking at least 1 pack per week at 1 year of follow-up. RESULTS: For the nondepressed, multivariate modeling revealed that current cigarette smoking was the strongest predictor of developing high depressive symptoms in all models (final model odds ratio [OR]: 3.90; 95% confidence interval [CI]: 1.85,8.20). For noncurrent smokers, although in bivariate analyses, baseline high depressive symptoms increased the risk of heavy smoking nearly threefold, multivariate modeling revealed that baseline high depressive symptoms were not predictive of heavy smoking when controlling for other determinants of smoking in teens. Previous experimentation with smoking was the strongest predictor of becoming a heavy smoker (OR: 3.04; 95% CI: 1.93,4.88). CONCLUSIONS: In contrast to common dictum, depression does not seem to be an antecedent to heavy cigarette use among teens. However, current cigarette use is a powerful determinant of developing high depressive symptoms.

Resident-centered care in assisted living.

Residents (n = 396) at 20 assisted living (AL) settings were interviewed as were program staff and administrators to understand how resident choice, getting needed care, and a sense of community were promoted or hindered. Residents reported relatively independent and autonomous lives, yet many experienced unmet health and long-term care needs and limited participation in meaningful activities or community life. Strong support was found for the hypothesis that AL program and site features influence resident experiences, particularly in regard to supporting independent lifestyles, minimizing avoidable care problems, and increasing community involvement.

Measuring the adequacy of home care for frail elders.

Community elders (N = 330) were interviewed by telephone twice at baseline using both computer-assisted telephone interviews (CATI) and nurse clinicians, and at four-month follow-up using CATI to collect alternative paraprofessional home care adequacy measures. Measurement format influenced both reliability and observed levels of adequacy but alternative adequacy measures converged and were not closely linked to functional status. The predictive validity of measures based on clinical standards with respect to health outcomes was also demonstrated. These findings support emerging approaches in primary care and home health quality measurement that consider multiple dimension of user response to formal and informal care.

Client-centered case management. A survey of state programs.

With funding from the Administration on Aging, the National Resource Center: Diversity and Long-Term Care surveyed state administrators of programs serving elders in 24 states in 1994. This survey sought to document what written guidelines and training case managers receive in promoting client autonomy in care planning. In discussions with respondents and review of written materials provided by the states, surveyors explored whether clients received written information about services, the structure for seeking client input into care planning, and the structure for soliciting client feedback once the care plan was in place. Of the states included in this survey, few have developed and implemented guidelines or provide case managers training to promote client autonomy in the care-planning process. After reviewing the survey findings, the authors make two policy recommendations for states to consider in this area.

Health care access, health promotion, and older women of color.

The U.S. population is becoming increasingly older due to steady increases in longevity, especially among women. Statistics show that older women, those 65 and over, outnumber older men by three to two. It is likely that as this trend in longevity continues, older women will continue to outnumber older men. The health care system must respond to these changes in the population by incorporating appropriate modifications into every aspect of the system, including financing mechanisms, service organization and delivery, consumer-centered care approaches, quality assurance mechanisms, and health promotion efforts. This article discusses the longevity advantage of women (particularly women of color) and its implications for economic insecurity, underinsurance of health care, health status, functional disability, access to care, and service use. The article concludes with a discussion of the challenges and opportunities presented as health care reform and the devolution of federal roles continue to unfold.

A contextual approach for understanding individual autonomy in managed community long-term care.

This article develops a framework for identifying community long-term care program and policy features that support or hinder client autonomy. After introducing the topic, the authors develop a contextual approach for understanding individual autonomy and discuss its relevance to community long-term care. They also illustrate how current financing, organization, and delivery of community long-term care provide clients with opportunities for meaningful choice. The authors summarize the implications that a contextual autonomy approach has for both community long-term care policy and program features and make specific policy recommendations.

Integrating acute and long-term care.

Advocates of health system reform are striving to assure that a valuable new benefit for home- and community-based long-term care is included. Yet in many legislative proposals, a long-term care benefit is kept separate from the rest of the benefit package. Experience from the social health maintenance organization (social HMO) demonstration shows that for the elderly at least, community long-term care can be integrated with acute care, at a manageable cost. Acute and chronic disease and disability are experienced concurrently. Moreover, disability is not confined to a small group of permanently disabled persons but affects many other persons for short periods. Integration of long-term and acute care in a managed care model serving a broad population may promote more effective acute care and more efficient and affordable long-term care.

Stability of frailty in the social/health maintenance organization.

Although many long-term care (LTC) programs assume that the disabilities of their frail elderly participants are stable in nature, there has been suggestive evidence to the contrary. This study tests stability of disability among social/health maintenance organization (S/HMO) members who were judged eligible for admission into a nursing home. Identified persons were reassessed quarterly. By the end of 1 year, less than 50 percent were still considered to be nursing home eligible. Logit analysis revealed an increased likelihood of instability for persons who were newly identified as functionally disabled after hospitalization. Policy implications for capitated managed-care programs for the elderly are discussed.

The administration of eligibility for community long-term care.

Eligibility assessment systems for community long-term care vary widely across current programs funded by states and Medicaid and in proposals to expand federal funding. Improved equity and efficiency in both current and proposed programs will require better specification of eligibility criteria, timing and setting of assessments, language of assessment items, training of assessors, procedures for appeal and review, and consideration of the costs of care management. Recent research and demonstrations provide models and technology for more uniform approaches in national programs.

Economic rationality, the affordability of private long-term care insurance, and the role for public policy.

This study uses data from the 1984 panel of the Survey of Income and Program Participation (SIPP) of the U.S. Bureau of the Census to develop new estimates of the potential market for private long-term care insurance. It found that this market is potentially significant--especially among individuals in the 65-69 age group who are willing to spend up to 50% of their discretionary income on such insurance--but considerably lower than previous estimates, such as those of Cohen and colleagues (1987).

Variations in care planning practice in the social/HMO: an exploratory study.

In this exploratory study, we examined the influence of provider settings, organizational structures, and community climates on long-term care resource allocation. We analyzed care plan decisions at each of the four Social/HMO sites for the same seven clients. Differences by site were found in eligibility determination and allocation of care plans, as well as types and mix of services prescribed. Issues are raised about the influence of provider settings on legitimation of types of needs and clients that are served.

Case management for frail elders: the Robert Wood Johnson Foundation's Program for Hospital Initiatives in Long-Term Care.

This evaluation of 24 hospital-based case management services found that case management could take a variety of forms, ranging from postacute medical management service to planning community-based care for potential long-term care users. Future research should concentrate on documenting the costs and outcomes of various models of case management in acute care settings.

A descriptive framework for new hospital roles in geriatric care.

Changes in demographics and in the operating environments of acute care hospitals have resulted in the development of new geriatric service products. Presented in this article is a framework for describing the variety of new services in terms of sponsor goals and core activities. Five broad types of geriatric service developments are described: geriatric medical care, post-acute care, transition management, chronic care, and information services. Assessing the implications of new services for the organizational functioning of hospitals is discussed, followed by an examination of the potential contributions of new geriatric services to the quality and accessibility of geriatric care.