Community-based Care

After accounting empirically for methodological differences, three national population-based surveys from the period between 1999 and 2002 provide similar estimates of the size and characteristics of the older residential care population: About 2.2 million persons age 65 or older (6.5 percent) live in supportive settings, about 1.45 million of them in nursing homes and nearly 800,000 in alternative residential care. Depending on survey definitions of "facility" versus community settings, however, the estimated proportion of the residential care population in “community” settings ranges from about half to three-quarters. Elders in community residential care appear to have less severe disability and are far more likely to report no ADL or IADL disabilities than those in “facility” alternatives to nursing homes. The age and gender distribution of persons in residential care alternatives and nursing homes is similar, but those in residential care alternatives more likely to be white and less likely to have extremely low incomes.

It is widely known that improving access to ambulatory care helps prevent hospitalizations for ambulatory care sensitive conditions. The Children's Health Initiative of Greater Los Angeles (CHI) formed in order to improve children's access to primary care by increasing Medi-Cal and Healthy Families enrollment. Previous reports showed the CHI reduced the overall rate of preventable hospitalizations in low-income children. This study examines if the CHI similarly reduced preventable hospitalizations for low-income children in Los Angeles County by analyzing hospitalization rates in Los Angeles for lower income compared to higher income children, and calculating hospitalization rates for ambulatory care sensitive conditions.

The roughly 30 million newly insured Americans will generate about $40 billion in new revenues for all hospitals by 2019, about twice as much as the Medicare payment cuts and the reductions in payments that will be made to offset the reduced costs of uncompensated care. For the most part, the payment changes that affect hospitals represent a modest move in the direction of paying for value rather than volume. More substantial changes, such as using forms of global payments to produce more fundamental alterations in hospitals’ business model will be tested in pilots and demonstrations.

This study estimates how informal care, paid formal care, and caregiver stress or burden relate to nursing home placement. Data came from the 1999 National Long Term Care Survey and were merged with administrative data. Results show that stress is a strong predictor of entry over follow-up periods of up to two years, and physical strain and financial hardship are important predictors of high levels of caregiver stress. The estimates indicate that reducing these stress factors would significantly reduce caregiver stress and, as a result, nursing home entry. We conclude that initiatives to reduce caregiver stress hold promise as a strategy to avoid or defer nursing home entry.

Understanding the role of informal caregiving in keeping chronically disabled elders out of nursing homes is increasingly important for policy. Demographic shifts are likely to increase the caregiving burden for a smaller number of caregivers per elder in the coming decades. This study examines how informal care, paid formal care, and stress or burden experienced by caregivers relate to nursing home placement. Data are from the 1999 National Long Term Care Survey and Informal Caregiver Survey merged with Minimum Data Set and other external data. Results from instrumental variables models indicate that stress is a strong predictor of nursing home entry over follow-up periods of up to two years, and that caregiving-related physical strain, financial hardship, and recipient behavior problems are important predictors of high levels of caregiver stress.