Why not just ask the resident?

This research evaluated a draft preference assessment tool (draft-PAT) designed to replace the current Customary Routine section of the Minimum Data Set (MDS) for nursing homes. The draft-PAT was tested with a sample of nursing home residents to evaluate survey-level administration time and noncompletion rates, as well as item-level nonresponse rates, response distributions, and test-retest reliability. Modifications to the draft-PAT were then retested with a subsample of residents. Completion times were brief (generally less than 10 minutes), and only a small percentage of residents were unable to complete the interview. Item-level nonresponse rates were low for the draft-PAT (0% to 8%) and even lower during retesting for items advanced to the national field trial (0% to 4%). Item response distributions indicated reasonable use of all options across both testing occasions, and item-level test-retest reliability was high. This study found that nursing home residents can reliably report their preferences. Eighteen items from the modified draft-PAT were advanced to the national field trial of the MDS 3.0. Inclusion of the PAT in the MDS revision underscores increased emphasis on including residents' voice in the assessment process.

What the resident meant to say: use of cognitive interviewing techniques to develop questionnaires for nursing home residents.

PURPOSE: Emphasis on consumer-centered care for frail and institutionalized older adults has increased the development and adaptation of surveys for this population. Conventional methods used to pretest survey items fail to investigate underlying sources of measurement error. However, the use of the cognitive interview (CI), a method for studying how respondents answer survey items, is not well established or documented in this population. This study demonstrates how CIs can be used to improve questionnaires intended for nursing home residents. DESIGN AND METHODS: CIs were conducted with 29 nursing home residents in order to identify potential problems with prospective survey items. We used scripted probes to standardize the interviews and adapted the Question Appraisal System to enumerate and classify the problems discovered. RESULTS: We fielded between one and five versions of each item in an iterative process that identified 61 item-specific problems. Additionally, residents' cognitive responses suggested that some screened their answers on the basis of perceived physical and environmental limitations, and some had difficulty answering items about preferences that fluctuate day to day. These findings led us to modify the items and response set to simplify the respondents' cognitive task. IMPLICATIONS: This study illustrates how CI techniques can be used to understand residents' comprehension of and response to survey items.

Reduced mortality: the unexpected impact of a telephone-based care management intervention for older adults in managed care.

OBJECTIVE: This analysis evaluated mortality over 24 months for Medicare managed care members who participated in the Care Advocate Program (CA Program) designed to link those with high health care utilization to home- and community-based services. DATA SOURCE: Secondary data from the CA Program, part of the California HealthCare Foundation's Elders in Managed Care Initiative. STUDY DESIGN: Randomized-control trial in which participants (N=781) were randomly assigned to intent-to-treat (ITT) and control groups. ITT group received telephonic social care management and 12 months of follow-up. Various multivariate analyses were used to evaluate mortality risk throughout multiple study periods controlling for sociodemographic characteristics, health status, and health care utilization. POPULATION STUDIED: Older adults (65+) enrolled in a Medicare managed care plan who had high health care utilization in the previous year. PRINCIPAL FINDINGS: ITT group had a significantly lower odds of mortality throughout the study (OR=0.55; p=.005) and during the care management intervention (OR=0.45; p=.006), whereas differential risk in the postintervention period was not statistically significant. Other significant predictors of mortality were age, gender, three chronic conditions (cancer, heart disease, and kidney disease), and emergency room utilization. CONCLUSIONS: Findings suggest that the care advocate model of social care management affected mortality while the program was in progress, but not after completion of the intervention phase. Key model elements accounted for the findings, which include individualized targeting, assessment, and monitoring; consumer choice, control, and participant self-management; and bridging medical and social service delivery systems through direct linkages and communication.

Reductions in costly healthcare service utilization: findings from the Care Advocate Program.

OBJECTIVES: To determine whether a telephone care-management intervention for high-risk Medicare health maintenance organization (HMO) health plan enrollees can reduce costly medical service utilization. DESIGN: Randomized, controlled trial measuring healthcare services utilization over three 12-month periods (pre-, during, and postintervention). SETTING: Two social service organizations partnered with a Medicare HMO and four contracted medical groups in southern California. PARTICIPANTS: Eight hundred twenty-three patients aged 65 and older; eligibility was determined using an algorithm to target older adults with high use of insured healthcare services. INTERVENTION: After assessment, members in the intervention group were offered mutually agreed upon referrals to home- and community-based services (HCBS), medical groups, or Medicare HMO health plan and followed monthly for 1 year. MEASUREMENTS: Insured medical service utilization was measured across three 12-month periods. Acceptance and utilization of Care Advocate (CA) referrals were measured during the 12-month intervention period. RESULTS: CA intervention members were significantly more likely than controls to use primary care physician services (odds ratio (OR)=2.05, P<.001), and number of hospital admissions (OR=0.43, P<.01) and hospital days (OR=0.39, P<.05) were significantly more stable for CA group members than for controls. CONCLUSION: Results suggest that a modest intervention linking older adults to HCBS may have important cost-saving implications for HMOs serving community-dwelling older adults with high healthcare service utilization. Future studies, using a national sample, should verify the role of telephone care management in reducing the use of costly medical services.

Does payment structure influence change in physical functioning after rehabilitation therapy?

PURPOSE: To determine if there are differences by payment structure (Medicare managed care versus fee-for-service) in the duration and intensity of geriatric rehabilitation therapy treatments and measure their effect on change in physical functioning at discharge. METHODS: Sixty-eight Medicare managed care (MCO) and 32 fee-for-service (FFS) subjects from 3 skilled nursing facilities (SNFs) in Southern California answered the physical functioning dimension of the Sickness Impact Profile (SIP-PFD) before and after rehabilitation therapy. Patient characteristics at admission, therapy treatments, and discharge physical functioning were compared by payment structure using chi-square and t-tests; logistic and ordinary least squares (OLS) regressions were employed to determine significant predictors of enrollment in managed care and change in physical functioning at discharge. RESULTS: Payment structure yielded no significant differences in patient characteristics (physical functioning, socio-demographics, and clinical characteristics) at admission to rehabilitation. Compared to MCO subjects, FFS subjects received significantly more minutes per day (intensity) of rehabilitation therapy (Mean difference = - 16.90; t-test = - 4.504; p =.000). On average, all subjects reported significant, positive change in physical functioning from admission to discharge after rehabilitation (Mean change = 7.98, SD = 12.96; t-test = 6.157; p =.000); but change in physical functioning between MCO and FFS subjects was not significant. CONCLUSIONS: Payment structure did not significantly influence change in physical functioning at discharge. Future studies, using a larger sample- size, should consider the effects of structural elements, process, and patient behavior on therapy treatments and physical functioning outcomes.

Using interagency collaboration to serve older adults with chronic care needs: the Care Advocate Program.

This article describes the Care Advocate Program, an interagency collaborative effort that involved health care organizations, social service agencies, and an academic research center to improve chronic care service delivery to older adults. The article discusses existing barriers to effective chronic care delivery as well as concepts for successful collaboration. The article describes the multiple and often competing demands of stakeholders who undertake collaborative projects. It concludes with lessons learned when partners from different settings work together to design and implement a demonstration program.

Partnering managed care and community-based services for frail elders: the care advocate program.

OBJECTIVES: To describe a demonstration program that uses master's-level care managers (care advocates) to link Medicare managed care enrollees to home- and community-based services, testing whether referrals to noninsured services can reduce service usage and increase member satisfaction and retention. DESIGN: Using an algorithm designed to target frail, high-cost users of Medicare insured healthcare services, the program partners PacifiCare's Secure Horizons and four of its medical groups with two social service organizations. SETTING: Three care advocates located in two community-based social services agencies using telephone interviews to interact with targeted elders living in the community. PARTICIPANTS: Three hundred ninety PacifiCare members aged 69 to 96 receiving care from four PacifiCare-contracted medical groups. INTERVENTION: The 12-month intervention provides telephone assessment, links to eight types of home- and community-based services, and monthly follow-up contacts. MEASUREMENTS: Sociodemographic characteristics of intervention participants, types of service referrals, and acceptance rates. RESULTS: Lessons learned included the importance of building a shared vision among partners, building on existing relationships between members and providers, and building trust without face-to-face interactions. CONCLUSION: The program builds on current insured case management services and offers a practical bridge to community-based services.