Beneficiary profiles and service consumption patterns in an urban Medicaid home and community-based waiver program.

The research reported here was conducted as part of a larger program evaluation of an urban Medicaid Home and Community Based-Waiver Program (HCBS). Informed by a secondary analysis of data collected on 723 clients, this article describes the association between client demographics and service consumption patterns among program beneficiaries with emphasis on access to care issues. The majority of the clients were female, African American, nearly 80 years of age, receiving approximately $600 of monthly income. Although White clients on average were higher functioning, they were hospitalized more frequently and took more medications than African American or Hispanic clients. Clients who were bedbound, Hispanic, and most dependent in performing activities of daily living received the fewest "number of services." Clients who suffered the most severe intellectual impairment, living with a spouse, and with the highest incomes received the most "units of service." Interestingly, service usage did not always increase as the client became more dependent in Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and mobility. The significance of findings is considered in relation to access to care issues.

Comparison of the high-tech service delivery experiences of hospice and non-hospice home health providers.

This study examined the degree to which national samples of hospice and non-hospice home health care agencies (N = 154) present different organizational profiles and grapple with different patient capacity issues when delivering technology-enhanced services to incapacitated elderly. Hospice agencies employ more part-time staff, make more in-home visits, see more high-tech patients, and provide a wider range of high-tech services than non-hospice providers. Factor analysis of index data confirms that hospice staff have more experience (p < .05) addressing the legal/ethical dimensions of care. Specifically, hospices deal with "right to die" issues more often (p < .05), but not with "delegation of authority" and "patient rights" issues. More agencies of both types have policies for handling decisions about life-sustaining treatment than for dealing with patients having questionable decision-making capacity. Needed agency policies for dealing with limited patient decision-making capacity in hospice and non-hospice home care agencies are reviewed.

Telemedicine: extension to home care.

Although there are multiple challenges facing the use of telemedicine in home health care, it seems likely that they will be resolved. This analysis projects significant increases in productivity and savings to be realized by implementing a telemedicine system (such as the Tevital Home Care System) compared with traditional home care services. Additional savings are expected as a result of the reduction in the utilization of medical services other than home health care. At the same time, telemedicine offers conceivable benefits such as improved access for consumers, extended coverage capability by home health care agencies, decreased inefficiencies attributable to the complications associated with agency personnel travel, improved agency capacity for preventive care, and, ultimately, heightened consumer satisfaction and both physical and psychological well-being. Taken together, these benefits make adoption of telemedicine technology by home care providers highly desirable.

Supporting patient autonomy: decision making in home care.

This study examines the policies and procedures that home health care agencies have developed to handle the incapacitated patient and life-sustaining treatment decisions. Data collected from a survey of 154 home health care agency directors and interviews with 92 local agency staff (including nurses and social workers) and 67 patients confirmed that directors, staff, and patients agree that patients are informed about their legal rights. When asked about specific rights, fewer patients were aware of their right to execute an advance directive, and even fewer patients had actually executed one. Only 67 percent of agencies reported having existing policies on advance directives and life-sustaining treatment decisions, whereas 41.5 percent had policies on how to handle the patient with questionable decision-making capacity. Consistent policies are needed for social workers, nurses, and other staff to handle such difficult ethical dilemmas. A review of specific agency policies is presented with recommendations for future policy changes and development.

Patterns of targeting and encouraging participation of elder consumers in human services marketing.

Competition within the older adult services sector is fueling the widespread adoption of an organizational marketing mentality. Yet little is known of the degree of variation in marketing technology and commitment to elder consumer subgroups in different health and social service settings or the extent to which elders are involved actively in the marketing process. This paper addresses these issues drawing on study data collected from 274 elder service programs in six major U.S. metropolitan areas. Findings confirm that providers frequently co-market their services with other organizations and target multiple constituencies, but do not distinguish as well among specialized segments of the elder population varying in terms of gender, physical and mental capacity, age, financial status, or race. Significant predictors (p<.05) of increased levels of elder participation in the agency marketing pro cess include length of time marketing, specialized training in marketing, and nonsectarian auspice (R2=.22). Results lead to recommendations for mounting more cohort-sensitive marketing initiatives in human service agencies serving older adults.

Provider and consumer profiles of traditional and high-tech home health care: the issue of differential access.

This study, based on data from 154 home health care agencies, examines the comparative profiles of traditional and technology-enhanced, or "high-tech", home health care service providers and recipients. Voluntary, not-for-profit agencies have been providing services the longest, serve more patients, make more home visits, and have more staff. However, proprietary programs have grown faster than agencies under other auspices. One in 10 patients receives high-tech care, with hospice agencies serving the largest proportion of high-tech patients. High-tech patients are more likely to be younger, male, married, white, and living with others than other service recipients in general. A slight majority of agencies have special admissions criteria for high-tech patients. Variations in the profiles of traditional and high-tech patients are considered in terms of their implications for differential access to particular categories of in-home services.

High-tech home health care: administrative and staff perspectives.

This study examines staff perspectives and personnel issues related to the delivery of high-tech home health care services to older adults. Data were collected from a national sample of 154 agency directors and 92 local agency staff. Agency staff and directors consistently report an increase in high-tech service delivery over the past five years. Both agency directors and local staff agree that a variety of staff may be involved in the delivery of high-tech services, including both professional and paraprofessional staff. Although agency directors report providing training to at least one or more type of direct care staff, agency staff are less likely to report being required to participate in training programs. The provision of high tech services impacts the agency, the staff, and the patient in various ways. Most staff feel that high-tech care enhances the quality of life of older patients, although high-tech care may be somewhat difficult to define and even more difficult to deliver. Challenges related to the provision of high-tech care, including providing adequate staff training, and developing appropriate quality assurance measures, are discussed.

The effectiveness of services marketing: perceptions of executive directors of gerontological programs.

Interest in marketing services, as opposed to products, has gained considerable momentum in recent years. The author conducted a survey of human service executives in six metropolitan areas to gauge the current status and efficacy of marketing efforts in programs for the aged. Findings confirm that the majority of health and social service organizations now employ marketing strategies of some kind, although somewhat insensitive and inadequate. The most common indicator of marketing success has been increments in the number of clients served. Health organizations are significantly more likely to measure the effectiveness of marketing efforts than social service agencies. Agencies commonly employ multiple marketing strategies, with face-to-face approaches proving to be the most effective. Least effective are public service messages and commercials on television/radio. The author suggests recommendations for mounting more efficacious and sensitive marketing programs in the human services.

A comparative cost analysis of alternative models of adult day care.

An analysis of the component costs of adult day care (ADC) programs in the Commonwealth of Pennsylvania indicates widely varying experiences in terms of fiscal and contractual administrative arrangements. Medical model ADC, program-funded services, and those agencies performing their own client assessments reported higher client per diems than the social model, slot-funded, and non-ADC assessed programs. For-profits displayed cost characteristics similar to their not-for-profit counterparts. Medical and slot-funded programs more frequently turned to multiple sources for budget supplementation. All program types tended to depend on voluntary client contribution methods as compared to means-tested approaches when determining fee-for-service.

Elder consumer preferences of marketing strategies in the human services.

The marketing of health and social services to the aged is a relatively recent phenomenon. To explore the role of the older consumer in service marketing, a national analysis of preferred marketing methods in gerontological programs was carried out. Eighteen focus groups comprised of senior center participants (mean = 73.8 years) in six metropolitan areas was conducted (n = 220). Findings document considerable consensus across gender, ethnic, socio-economic, and racial cohorts. Preference was expressed for personal/direct forms of marketing. Regardless of age or level of infirmity, subjects identified with images of active and healthy elders. Sharp distinctions were drawn between marketing conducted by for-profit and not-for-profit organizations, as well as between marketing with a "selling" purpose versus that which is primarily informational. Results lead to recommendations for elder service providers on mounting a meaningful program of marketing initiatives. Supported by a grant from the AARP Andrus Foundation.

The evolution of private geriatric care management. Guidelines for responsible practice.

Fueled by a series of demographic, occupational, and programmatic trends, private firms providing care management services to the elderly and their families have experienced rapid growth. A range of leadership challenges faces social workers entering this specialty. Exemplary ethical and professional behavior will ultimately determine the extent to which private geriatric care managers become a central component of the gerontological services network.

Service consumption patterns over time among adult day care program participants.

A study of 59 adult day care (ADC) programs funded by area agencies on aging in Pennsylvania provides data which profiles the classic package of ADC services utilized by elder participants and traces the relationship between formal service consumption and the helping behaviors of family caregivers. Elder clients rejected 1 or more services offered by ADC staff 59% of the time. Consumption of homemaking, transportation, and counseling services escalated over time although total formal services used remained minimal. Family helpers performed both a greater range and intensity of support functions as compared to ADC programs (p less than .001). Program strategies and future research directions are suggested.

Men as elder caregivers: a response to changing families.

Results are presented from a study that examined the relationship between gender orientation and the unique stresses and gratifications for men who are engaged in caregiving tasks traditionally performed by women. The men report having found emotional gratification an important motivating factor, and they tended to ascribe to themselves many affective traits usually associated with the female role.

Role divergence and complexity in gerontological home care.

This study documents high levels of role complexity and functional overlap in the field of home health care. Personnel perform a wide range of "professional/organizational" and "community/familial" service functions though the emphasis is on the delivery of a battery of pseudo family-like tasks. The importance of a familial orientation does not significantly decline when controlling for length of employment or organizational rationality. Role orientation is, however, significantly associated with a worker's chronological age. Results lead to program planning recommendations meant to influence staff training paradigms in home health care.

Assessing the community care needs of the functionally impaired elderly: the gerontological worker's perspective.

A survey study of home care workers (N = 91) in three federally funded home care programs sheds light on the perceived community care and support service needs of the functionally impaired elderly. Findings also serve to identify those variables which may influence the accuracy and/or legitimacy of needs assessment data, especially when such information is collected from the perspective of the gerontological community worker. Results indicate that professional home care staff are able to more clearly define a finite set of high priority home-delivered services for the elderly. On the other hand, paraprofessional personnel as a group do not agree as easily on a specific set of community support services meriting top priority. Their diffused notion of priority expressed itself in responses regressing to the mean. As a source of targeted needs assessment data, paraprofessional staff may reflect a lesser capacity to selectively set priorities. On the other hand, their responses seemingly reflect a weaker tie to disciplinary biases. The implications of these study data are discussed in terms of the process and methodology of community need assessment for the elderly and the target groups to which program planners will want to seek evaluations of service need in the future.

Home care for the aged: a fragile partnership.

To what extent do the efforts of relatives, friends, and professional caregivers coalesce or clash in serving the home-bound elderly? This article presents data suggesting that the influence of natural support networks on formal service provision may be negative at times. Results indicate that one set of home care services may be provided more frequently and more effectively by relatives and friends and another set more appropriately by professional home care workers.

Measuring the extent of gerontological home care staff participation in agency policy making and planning.

A survey study of the work experience and views of administrative and direct service program staff (N = 91) in both small scale and large scale Older Americans Act-funded home care programs in New York City sheds light on the extent to which various categories of personnel in the field of community home care have opportunities to participate in a range of agency policy making and planning functions. Findings reveal that home care staff in small scale programs were more directly involved in both client-centered and program-centered policy/making activities. In particular, these workers felt they were significantly more active in: changing service plans; discussing changes that need to be made in how the agency operates; planning new services and programs at the agency; and helping to train or orient new workers in the program. A strong negative correlation between level of organizational complexity and worker participation rates was discovered. Additional data suggest that all staff, regardless of their status or work responsibility, would like to be granted more of a voice in planning decision. Those who participate least in such activities were most adamant over being given a greater role in this aspect of program life. Heightened levels of job satisfaction were also associated with greater measures of worker involvement in organizational decision-making. Study findings are seen to have implications for the design of more equitable decision-making mechanisms in gerontological home care specifically and human service programs generally.