Lessons learned from the Medicare Alzheimer Disease Demonstration.

The Medicare Alzheimer Disease Demonstration tested a case management and community care benefit for persons with dementia. The demonstration produced statistically but not clinically significant reductions in caregiver burden and depression. It increased access to community-based long-term care services but did not affect the level of services used. It did not reduce informal caregiver hours spent helping people with dementia. It produced statistically significant but not budget-neutral reductions in Medicare expenditures in that the degree of reduction in regular Medicare expenditures was not enough to offset the added demonstration costs. It did not reduce rates of nursing home placement. Informal care networks providing care to demented enrollees were generally able to function effectively, regardless of whether a professional case manager was involved or whether a long-term care benefit was available.

Effects of the Medicare Alzheimer's Disease Demonstration on the use of community-based services.

STUDY QUESTION: Did the Medicare Alzheimer's Disease Demonstration with its case management and community service waivers affect the use of community-based long-term care services among people with dementia and their primary caregivers? DATA SOURCES: Baseline and periodic caregiver interviews. Measures include client and caregiver attributes and self-reported service use. STUDY DESIGN: The demonstration randomly assigned voluntary applicants into treatment and control groups. Treatment group cases were eligible for case management and for up to $699 per month in community care benefits. The actual monthly entitlement varied among the eight demonstration communities due to regional cost and inflation adjustments over time. Analyses are for the year after enrollment. DATA COLLECTION: Analyses are of cases surviving six months or more in the community after enrollment (n = 5,209). Cases received baseline and semi-annual assessments. PRINCIPAL FINDINGS: The intervention of case management and community service reimbursement had a strong, consistent, and positive effect on the likelihood of using home care (including homemaker/chore services, personal care services, companion services) and adult day care. Treatment group clients were at least twice as likely as control group clients to be using any of the four community-based services. A similar, but less pervasive effect was achieved with caregiver training and support group participation. Reimbursement provided by the demonstration's Medicare waiver was generally not sufficient to exceed the level of control group service acquired through private payment. CONCLUSIONS: Reimbursement levels within the demonstration may have enabled more individuals to purchase some services, but they were not sufficient to increase the average level of use over those in the control group. No consistent differences between demonstration models were found in service use likelihood or average use among users.

Effects of the Medicare Alzheimer's Disease Demonstration on caregiver burden and depression.

STUDY QUESTION: Does improved access to community-based care reduce perceived burden and reported levels of depression among primary caregivers of people with dementia? DATA SOURCES: Baseline and periodic caregiver interviews with participants in the Medicare Alzheimer's Disease Demonstration. Client and caregiver attributes and caregiver outcomes such as depression and burden scores were among the measures. STUDY DESIGN: Applicants to the demonstration (all voluntary) were randomly assigned into treatment and control groups. Treatment group cases were eligible for case management and for up to $699 per month in community care benefits. (The actual monthly entitlement varied among the eight demonstration communities due to regional cost differences and inflation adjustments over the four-year demonstration period.) DATA COLLECTION: A total of 5,307 eligible individuals received a baseline assessment at the time of application to the demonstration and at least one semi-annual reassessment. Clients and their caregivers were periodically reassessed producing a total of 20,707 observations. PRINCIPAL FINDINGS: Persons in the treatment group had a high exposure to case management and a greater likelihood of community service use relative to those in the control group. Treatment group membership was associated with statistically significant, but very small reductions in caregiver burden (in four of eight sites) and depression (three of eight sites) over a 36-month tracking period. These findings are not sustained with all cases combined, or among a higher-resource demonstration model considered separately. CONCLUSIONS: Both the fact that these programmatic differences did not translate into substantial treatment group reductions in caregiver burden or depression, and the consistency of these findings with those of prior case management evaluations suggest the need to reformulate this programmatic intervention into areas not previously tested: 24-hour care, crisis intervention, coordination with primary care, or chronic disease management.

Caregiver supports: outcomes from the Medicare Alzheimer's disease demonstration.

A randomized 3-year study assessed the effect of expanded community-based services and case management on 5,254 caregivers of dementia clients. A tested policy concern was whether the financing of formal care would result in a reduction of informal assistance. Unmet needs task assistance for the demonstration's treatment group caregivers decreased by 30 percent within 6 months and by about 20 percent over 36 months relative to controls. While treatment group members used slightly more formal care over time, there were no differences between treatment and control groups in primary caregiver hours after 36 months, or in the number of tasks in which primary or secondary caregivers provided assistance.

Case mix controlled service use and expenditures in the social/health maintenance organization demonstration.

BACKGROUND: The social health maintenance organization (S/HMO) demonstration was implemented, in part, to determine if the presumed integration of acute and chronic care in these plans could produce sufficient savings to allow plans to offer expanded and chronic care benefits without increased cost to the Medicare program. METHODS: S/HMO members and a sample of fee-for-service (FFS) recipients were tracked over three years to assess their utilization experience. Analyses controlled for case mix, using Grade of Membership procedures. RESULTS: In 1987, the last year of risk sharing, S/HMOs reported higher total expenditures than FFS in each health status class. For the "healthy," differences were largest for physician care. In other classes, differences in nonskilled nursing or home care use were noted. In 1988, the first year of full risk, Seniors Plus had equivalent or lower expenditures relative to FFS for all classes. Elderplan had lower expenditures in four of six classes and provided more service to the "frail" and the "acutely ill." SHP had higher expenditures in all classes because of higher hospital and nursing home expenditures. Medicare Plus II had higher expenditures in all classes, for physician, nonskilled nursing home, and home care expenditures. CONCLUSIONS: Overall plan losses and higher expenditures among a number of case mix groups suggest a need for refinement of S/HMO operations--especially in case management relationships to medical care and in the selection of "high risk" cases.

Case management in the social health maintenance organization demonstrations.

In this article, case management departments and roles during the early years of the social health maintenance organization (S/HMO) demonstrations are compared. These organizations provide acute and chronic care services under a prepaid plan for the elderly. Eligibility criteria for case management and chronic care services at each site are compared, followed by a description of the resultant case mix of members receiving chronic care benefits. Case managers principal activities are described, and a preliminary assessment is made about the strength of the linkages that have been developed between the case management component of these plans and the larger health care system.