The Evolution of Long-term Care Programs; Comment on “Financing Long-term Care: Lessons From Japan”

The need for long-term care (LTC) represents a “new social risk,” one that overlaps with and complements systems of care that pre-date such programs, complicating LTC program design. This commentary expands on Ikegami’s discussion of how these structural factors must be accommodated, as well as historical and cultural factors that influence public expectations of such a program. The commentary specifically focuses on the role of cash payments, caregiver benefits, and the sometimes indistinct line between LTC and health systems. The experiences of countries operating LTC program in a wide range of contexts can illuminate common challenges, as well as some potential solutions to these vexing design and operational issues

The Alzheimer’s Association Dementia Care Coordination Program: A Process Evaluation, Executive Summary

The Massachusetts/New Hampshire (MA/NH) Chapter of the Alzheimer\u27s Association has long sought ways to systematically increase the number of families who utilize its services and support. According to the Alzheimer’s Association’s 2015 Alzheimer’s Disease Facts and Figures, there are 142,000 individuals living with Alzheimer’s disease in Massachusetts and New Hampshire, and the Alzheimer’s Association estimates that less than 30% of those individuals and their caregivers take advantage of its programs (Alzheimer’s Association, 2015). The MA/NH Chapter recognized that one major barrier to accessing services is a model that relies on families taking the initiative to seek out assistance. In 2005, The MA/NH Chapter of the Alzheimer’s Association initiated the Health Liaison Program. Rather than relying on affected persons to reach out to the Chapter, the Health Liaison Program sought to improve chapter service utilization by encouraging health care providers to make direct referrals for families affected by Alzheimer’s disease and related dementias (ADRD). After many years of operating the Health Liaison Program with existing staff, the Alzheimer’s Association MA/NH Chapter decided to pursue funding to expand the Health Liaison Program into the more formal Dementia Care Coordination (DCC) program. This study reports on the Dementia Care Coordination (DCC) Program. In 2013, with support from a non-profit health insurer, Tufts Health Plan (THP) and a private funder, the Eisenberg Family Trust, the development and implementation of the DCC Program became possible. Under the DCC Program, dedicated care consultants connect directly with persons with ADRDs and their families who are referred to the Chapter by health care providers. Once connected, the care consultant is able to provide disease-specific education, symptom management strategies, emotional support, and referrals to community resources and encourage the caregiver to utilize other Alzheimer’s Association services including support groups, education programs, and advocacy opportunities. Consultants collaborate with other staff members and volunteers to provide ongoing information and support to families. Moreover, consultants provide written feedback to health care providers and nurse case managers on client needs and recommendations to meet those needs. Connecting families affected by ADRD with the services and support of the Alzheimer’s Association has important benefits for both the caregiver and affected person. Integrating primary care with caregiver support will likely improve the health status and quality of life for the person with ARDA and family caregivers. Mittleman et al. (2006) has demonstrated that such support and education delays institutionalization and improves physical and emotional health outcomes for the caregiver. Unfortunately, many caregivers delay seeking any kind of assistance. Richardson (2012) reporting on a 2012 study by the Alzheimer Society of Canada, stated that 44% of caregivers for people with ADRD waited a year or more, after the first signs of dementia, to seek any kind of support. The overall finding of this study is that the DCC program is highly successful and has engendered high levels of satisfaction by participants and multiple stakeholders. The DCC program represents an important element in a comprehensive integrated approach to patient care. Our analysis has also led us to make recommendations on how this important program can be improved, with the hope that it can be expanded and replicated

Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS)

Background: Little is known about how the proportions of dependency states have changed between generational cohorts of older people. We aimed to estimate years lived in different dependency states at age 65 years in 1991 and 2011, and new projections of future demand for care. Methods: In this population-based study, we compared two Cognitive Function and Ageing Studies (CFAS I and CFAS II) of older people (aged ≥65 years) who were permanently registered with a general practice in three defined geographical areas (Cambridgeshire, Newcastle, and Nottingham; UK). These studies were done two decades apart (1991 and 2011). General practices provided lists of individuals to be contacted and were asked to exclude those who had died or might die over the next month. Baseline interviews were done in the community and care homes. Participants were stratified by age, and interviews occurred only after written informed consent was obtained. Information collected included basic sociodemographics, cognitive status, urinary incontinence, and self-reported ability to do activities of daily living. CFAS I was assigned as the 1991 cohort and CFAS II as the 2011 cohort, and both studies provided prevalence estimates of dependency in four states: high dependency (24-h care), medium dependency (daily care), low dependency (less than daily), and independent. Years in each dependency state were calculated by Sullivan's method. To project future demands for social care, the proportions in each dependency state (by age group and sex) were applied to the 2014 England population projections. Findings: Between 1991 and 2011, there were significant increases in years lived from age 65 years with low dependency (1·7 years [95% CI 1·0-2·4] for men and 2·4 years [1·8-3·1] for women) and increases with high dependency (0·9 years [0·2-1·7] for men and 1·3 years [0·5-2·1] for women). The majority of men's extra years of life were spent independent (36·3%) or with low dependency (36·3%) whereas for women the majority were spent with low dependency (58·0%), and only 4·8% were independent. There were substantial reductions in the proportions with medium and high dependency who lived in care homes, although, if these dependency and care home proportions remain constant in the future, further population ageing will require an extra 71 215 care home places by 2025. Interpretation: On average older men now spend 2·4 years and women 3·0 years with substantial care needs, and most will live in the community. These findings have considerable implications for families of older people who provide the majority of unpaid care, but the findings also provide valuable new information for governments and care providers planning the resources and funding required for the care of their future ageing populations. Funding: Medical Research Council (G9901400) and (G06010220), with support from the National Institute for Health Research Comprehensive Local research networks in West Anglia and Trent, UK, and Neurodegenerative Disease Research Network in Newcastle, UK

LTSS IS LOCAL, EVEN IN COUNTRIES WITH NATIONAL LTSS PROGRAMS

Abstract This study reports the results of a cross-national qualitative assessment of how different countries structure their provision of long term services and supports (LTSS). It emphasizes the universality of the local role, even in countries that offer some form of universal coverage for LTSS. At minimum, countries devolve the responsibility for administration and eligibility determination to sub-national units, variously called provinces, départements, Länder, or other terms. However, many countries do much more than that: subnational units can be responsible for the safety net welfare programs that pick up the costs that the universal programs do not cover. They may also run other programs that affect the ability of people with LTSS needs to live good lives, such as housing and health programs; again, the role of sub-national governments often focuses on those least able to pay. In addition, in some countries, local governments have a role in helping to finance the national program as well. Differing abilities to support these responsibilities across regions can result in geographic disparities in access to care – so, too, can differences in administration and eligibility determination, resulting in many of the same issues that we in the US confront regarding access to LTSS through the Medicaid program. Thus, even countries with strong national programs for LTSS experience many of the same tensions between national and sub-national units of government that we in the US do.</jats:p

The Evolution of Long-term Care Programs Comment on "Financing Long-term Care: Lessons From Japan"

The need for long-term care (LTC) represents a "new social risk," one that overlaps with and complements systems of care that pre-date such programs, complicating LTC program design. This commentary expands on Ikegami’s discussion of how these structural factors must be accommodated, as well as historical and cultural factors that influence public expectations of such a program. The commentary specifically focuses on the role of cash payments, caregiver benefits, and the sometimes indistinct line between LTC and health systems. The experiences of countries operating LTC program in a wide range of contexts can illuminate common challenges, as well as some potential solutions to these vexing design and operational issues.</jats:p

ADMISSION AND CARE OF INDIVIDUALS WITH MENTAL ILLNESS IN MASSACHUSETTS NURSING HOMES: A PILOT STUDY

Abstract Due to the rising prevalence of mental illness in nursing homes (NHs), the US Congress passed the 1987 Pre-Admission Screening and Resident Review (PASRR) mandate, which aims both to limit inappropriate institutionalization of people with mental illness and to ensure that they are served appropriately when living in NHs. Although the PASRR is a federal mandate, states have considerable flexibility in implementing it, resulting in considerable variation across states. This study explores the Commonwealth of Massachusetts’ policies on admission and care of individuals with mental illness in NHs, focusing on implementation of PASRR regulations. Semi-structured phone interviews were conducted with key informants identified through purposive snowball sampling (N=8). Key informants included representatives from NHs, the State Mental Health Authority, state Medicaid office, and independent contractors and an academic expert. Data were analyzed using qualitative content analysis. Participants agreed that the PASRR tools efficiently identified and screened people with mental illness -- thus achieving PASRR’s first aim, but that the regulations did not successfully ensure appropriate services. Interviewees also identified a lack of services and options for diversion of people with mental illness into the community. Nursing home informants noticed a disconnect between the various supervising departments and felt instructions were unclear on the administration of the tool. This work builds a case for a national study to understand how PASRR implementation varies across states, resulting in variations in the proportion of people with mental illness admitted and served in NHs.</jats:p

Consumer Choice in Health Insurance Exchanges: Can We Make It Work?

Abstract Under the Patient Protection and Affordable Care Act (ACA), consumer choice plays a critical role: it drives the competitive market in health insurance plans that will operate through health insurance exchanges. As the 2014 deadline for establishing exchanges approaches, states face choices: they can either allow the federal government to manage an exchange on their behalf; take on a minimalist role by managing a state exchange or partnering with the federal exchange; or assume an activist role — by aiming to influence the price, design, and quality of the health insurance options available through exchanges and taking steps to support consumers' ability to choose among these options. This article discusses states' choices and the governance issues that they raise, first by describing the extent of discretion that states have in shaping the range of health plans on offer as well as the issues they will need to consider in choosing an exchange model. We then discuss the considerable body of evidence that addresses how people behave in individual insurance markets, concluding that it strongly supports the need for states to take an active role in shaping health insurance exchanges and ensuring that they support consumer choice.</jats:p