Outcomes among orthopedic patients in skilled nursing facilities: does managed care make a difference?

The use of rehabilitative care has increased greatly. This study evaluates whether managed care affects health outcomes among Medicare orthopedic patients receiving rehabilitative treatments. Managed care versus fee-for-service patients had better outcomes at four months following discharge from skilled nursing facilities. It is important to address predictive factors, such as age, length of hospital stay, debilitation and social living arrangements, which can also influence health outcomes when planning rehabilitative treatment for older patients.

Comparison of older adult subject and proxy responses on the SF-36 health-related quality of life instrument.

Studies of older adults' health status and health-related quality of life (HRQoL) often rely on proxy responses when subjects have problems that affect their ability to respond. With the increased interest in outcomes research in health care, it is important to examine proxy reliability on HRQoL instruments. This study compares 32 pairs of subject-andproxy responses on the eight subscales and two summary scales of the Short Form 36 (SF-36). Subjects and their proxies, recruited from senior centers and residential facilities, were interviewed face-to-face within a seven-day period. Subjects were 60 years of age or older and had passed a brief cognitive screen, and proxies were geographically proximate and had seen the subject during the past week. Results showed that although moderate intra-class correlations were found on six of the eight measures, an item-level kappa statistic indicated poor to fair agreement on all subscales except items of Physical Functioning and Role Physical. Moreover, paired t-tests revealed proxy mean scores that were significantly lower on the Physical Functioning, Vitality, and Mental Health subscales. Given the mixed findings, until further research is done, researchers and clinicians should exercise caution when using proxy responses for older adults with the SF-36.

A comparison of skilled nursing facility rehabilitation treatment and outcomes under Medicare managed care and Medicare fee-for-service reimbursement.

PURPOSE: This article compares the rehabilitation treatment and outcomes of Medicare managed care organization (MCO) and fee-for-service (FFS) patients in skilled nursing facilities (SNFs). DESIGN AND METHODS: Data on 514 MCO patients and 420 FFS patients treated in four for-profit Southern California-based SNFs between June 1996 and September 1998 were analyzed with bivariate and multivariate regression models. RESULTS: After controlling for time since onset and other sociodemographic and health status characteristics, Medicare MCO patients were found to receive significantly fewer therapy units and have significantly shorter lengths of stay in rehabilitation programs. IMPLICATIONS: The findings may be the result of more global differences in the trajectories of care among MCO and FFS patients treated in SNFs, yet they highlight critical issues related to the spread of Medicare managed care in nursing homes and the dynamic between MCO and FFS reimbursement systems.

Correlates of open- and locked-facility placement in a population of decisionally impaired adults.

OBJECTIVES: This study compares characteristics of public conservatees placed in locked facilities with those in less restrictive settings. Given the principle of the least restrictive alternative, the study seeks to identify factors, including the role of aging and advanced age, associated with restrictive placement within conservatorship. METHODS: Management Information Systems data on 1,534 adult conservatees in Los Angeles County in July, 1993, are examined in cross-section. Models exploring individual and environmental characteristics of conservatees and linear, curvilinear, and multiplicative aging effects are tested on the probability that adults are placed in locked facilities versus all other placement types. RESULTS: Locked facility placement is associated with being female, receiving SSI, a diagnosis of dementia, and being identified as a danger to oneself and to others. Locked-facility placement is associated with increasing age until age 60, when the effect becomes inversely related; the multiplicative effect of older age and impaired functioning is also inversely related. DISCUSSION: The curvilinear nature of age and the interaction effect of Age x Functioning implies that increasing frailty in older adults makes locked facility-placement less likely. Further research is needed on whether alternative placement types, such as special care units with secured perimeters, can further reduce the need for locked facilities.

Improving service delivery: provider perspectives on building community-based systems of care.

This article examines the views of service providers toward different public policy efforts to improve service delivery to elders requiring multiple services from an array of organizations. The authors examine the relationship between provider assessments of the adequacy of their community-based systems of care and community resource levels, coordination strategies, and client characteristics. Findings, based on responses from managers of programs serving older adults (n = 250) to a mailed survey, were that two-thirds (69.4%) evaluated their service delivery systems as adequate or better. A regression model used to explain system adequacy indicated that 22% of the variance was accounted for by community resource level, information and service availability, attention to specific need clients, and percentage of minority clients served by the respondents' programs. Findings suggest that community resource level appears to be an important factor in respondents' evaluation of system adequacy. While respondents indicated that improved coordination could enhance their efforts to deliver services, this strategy was not one they favored in improving their community-based system of care. Instead, they preferred strategies which expanded or improved the services that were available.

Rethinking alternatives to guardianship.

This article describes, compares, and analyzes the roles and functions of guardianship and several decision-making interventions previously identified as potential alternatives to guardianship. An analytical framework, comprised of capacity, risk, complexity, and support, is developed to assess performance expectations and identify limitations of four types of decision-making interventions. Using case examples to illustrate how the framework applies to practice, the capacity of different types of interventions to address needs and to substitute or divert older adults from guardianship is examined. The article concludes with propositions introduced to guide future research.

The search for effective alternatives to conservatorship: lessons from a daily money management diversion study.

This article explores outcomes of daily money management (DMM) services for older persons. It is based on research that examined the ability of DMM to provide an alternative to court-appointed conservatorship that is less restrictive. Results indicate that although the DMM programs studied did not divert older persons from conservatorship, they appeared to offer several important advantages. These included helping older persons secure benefits and services, enhancing their financial security, and reducing financial exploitation.

Developing a daily money management service model: navigating the uncharted waters of liability and viability.

This article discusses the development and implementation of a Daily Money Management (DMM) Service within a mature health and social service agency. Although there is increasing recognition of the need for DMM programs, major obstacles to their development include problems of securing adequate financial support and concerns about the liability risks inherent in providing financial services. This article describes an innovative DMM service model developed at Senior Health and Peer Counseling in Santa Monica, California, that has serviced more than 100 elders during its first two years of operation. The article explores the mission, key components and organization of the service model, including the development of a multidisciplinary Technical Advisory Group and a professionally supervised volunteer staff, the service planning and care coordination issues, the risk management protocols, and the need for multiple sources of financial support.

Alternatives to conservatorship: the role of daily money management services.

This study tested the hypothesis that daily money management services divert vulnerable elders from conservatorship. Community-residing elders referred to protective service were randomly assigned to a money management service (n = 40) or to customary screening by the Office of the Public Guardian or Adult Protective Services (n = 23). Results indicated no significant difference in rates of conservatorship between those who were offered the money management service and those who were not. Appointment to conservatorship for both groups was associated with cognitive impairment and psychiatric symptom severity.

Experiential learning in gerontology: methods for applying concepts and theories to practice.

Theories of developmental aging are a crucial component of professional training in gerontology and methods for applying these theories are equally important. Current models are presented which include a variety of opportunities to test theories and develop skills in the gerontology classroom. In addition, the methodology of field studies and consultation are discussed. Various practica models and the instructor's role in organizing and directing them are also presented.