Office of Disability, Aging and Long-Term Care Reports Online: 2009

A Literature Review: Psychiatric Boarding (October 2008)
This literature review explores the relevant literature on several key questions regarding boarding of psychiatric patients in the emergency department (ED). Is psychiatric boarding a problem? What are the reasons for boarding psychiatric patients? What kind of care is received while patients are boarded? Our review of the literature will delve into these questions as well as the impact of psychiatric patient boarding on others, including the financial impact. The authors discuss how the decisions of key players including ED staff, law enforcement, insurance companies and hospitals have a significant impact on the ED boarding process for psychiatric patients. Where possible, the authors provide data to support key findings. Finally, the authors highlight best practices and solutions regarding ED psychiatric boarding.

Full HTML Version: http://aspe.hhs.gov/daltcp/reports/2008/PsyBdLR.htm

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Advance Directives and Advance Care Planning: Report to Congress (August 2008)
This report comprises eight chapters. Chapter II discusses the terminology used in the field and in the remainder of the report. Chapter III provides a historical perspective and discusses ethical issues in advance care planning. Chapter IV discusses the structure and use of advance directives. Chapter V takes up the issue of advance care planning among persons with disabilities. Chapter VI discusses barriers to the completion of advance directives and to advance care planning. Chapter VII reviews interventions that have been implemented to promote advance care planning and advance directive use. Finally, Chapter VIII summarizes the state of the field and suggests future considerations for improving the use of advance care planning and advance directives. Details of the report's content can be found in the full literature review and commissioned papers, which are contained in Appendices B-E. Where appropriate, the reader is directed to Appendix papers for a more complete discussion of the topic.

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An Analysis of the Impact of Spenddown on Medicaid Expenditures (January 1992)
This study analyzes Connecticut nursing home data on a current resident cohort, with particular attention to how many residents began their stays as private pay, but eventually spent down to Medicaid eligibility. It also estimates how many residents were Medicaid eligible prior to admission or became eligible at admission. Using data on the amount of income that nursing home residents on Medicaid applied to their bills, the authors were able estimate the amounts of Medicaid funds provided for the care of various types of nursing residents. Those who spenddown received nearly 38% of Medicaid expenditures.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/spddwnes.htm

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An Exploratory Study of Certified Nursing Assistants’ Intent to Leave (September 2008)
High nursing assistant turnover is disruptive to quality of care and is costly. Findings from the first national probability survey of nursing assistants in nursing homes document the magnitude of potential turnover. In 2004, 45% of nursing assistants reported they were very or somewhat likely to leave their job in the next year, 24% were actively looking for another job, and 18% were extremely or somewhat dissatisfied with their job. Intent to leave was associated with job satisfaction, demographics, job experience, commitment to the field, and commitment to the job. This exploratory study underscores the importance of supervision, pay and benefits, and the work environment, suggesting that strategies for stabilizing the nursing assistant workforce address these issues. [29 PDF pages]

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Analysis of Risk Communication Strategies and Approaches with At-Risk Populations to Enhance Emergency Preparedness, Response, and Recovery: Final Report (December 2008)
In this report, the authors present the results of an assessment that involved review of the literature on emergency preparedness risk communication and public health messaging strategies; the compilation of educational and outreach materials for emergency preparedness communication with vulnerable populations; and site visits in three states and the Washington, DC, area to identify gaps in the practice of risk communication with vulnerable populations.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/2008/emergfres.htm

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Analysis of the California In-Home Supportive Services (IHSS) Plus Waiver Demonstration Program (July 2008)
This report documents IHSS Plus Waiver implementation and recipient Medicaid service use in calendar year 2005. Analyses compare recipients having a waiver-eligible provider (i.e., parents of children, spouses of adults) for any portion of 2005 with recipients in the regular IHSS program who received personal assistant services through other relatives and non-relative providers during the same period. Recipients are classified by these provider types of an "intention to treat" basis. Recipients changing between spouse/parent providers and non-waiver eligible providers are considered throughout the analysis as being in the spouse/parent group. This is analogous to an experiment where an individual enrolls into the innovative care group and later changes into "usual" care, but for purposes of analysis, the recipient is included within the group to which they were originally assigned.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/2008/IHSSPluses.htm

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ASPE Technical Expert Panel on Earlier Intervention for Serious Mental Illness: Summary of Major Themes (May 2009)
Current disability policy provides support for people with a mental illness once they are no longer able to work and thus qualify for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). The concept of earlier intervention involves providing services and supports for people before they are disabled enough to qualify for SSI or SSDI in order to keep them connected to employment, community and family life. One of the major challenges of intervening earlier is the need to align policies relating to income support, disability benefits, health care insurance and delivery, employment supports, rehabilitation services and evidence-based practices for the treatment and rehabilitation of mental impairments. This report is a summary of a Technical Expert Panel convened by ASPE in May 2009 to explore earlier intervention for this population.

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Assessing Home Health Care Quality for Post-Acute and Chronically Ill Patients: Final Report (August 2008)
Home health agencies serve patients with a range of health care needs including those with short-term post-acute needs and the chronically ill with more long-term needs. The purpose of this project was to examine the current approach to public reporting of Medicare home health agency quality with a particular focus on how quality measures perform for the diverse home health population. The results raise the possibility that public reporting is unfair to agencies admitting a relatively large share of patients who tend to have worse outcomes. In particular, agencies with a relatively large share of clinically complex community admissions could be disadvantaged compared to agencies serving a large share of post-acute restorative care patients. Analyses at the agency level, which were outside the scope of this project, are needed to understand the extent and impact of bias in risk-adjusted outcomes at the agency level as well as the relationship among agency and geographic factors, the types of individuals served, and patient outcomes. While many questions remain to be answered, the findings from this project in several areas provide critical information needed by the Department in its efforts to assess and improve the quality of care provided to the diverse home health population.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/2008/hhcquales.htm

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Assistive Device Use Among the Elderly: Trends, Characteristics of Users, and Implications for Modeling (September 2005)
This study adds to understanding by updating information on trends in use of disability equipment and exploring how disability and other characteristics differ for equipment users and nonusers. Data are from the 1984-1999 rounds of the National Long Term Care Survey, which has been a key source of earlier information on trends in equipment use. The authors examine several trends in the use of equipment over the period 1984-1999, including use of equipment with and without help, use of equipment for specific activities, and use of particular types of equipment. They then examine how disability, characteristics relating to the availability of potential caregivers and environmental accommodations, and socioeconomic characteristics differ for those using and not using equipment, and how hours of care vary by whether and how equipment is used. Finally, the authors discuss implications for of the findings for models relating to the role of assistive devices in managing disability.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/astdeves.htm

Report Summary: http://aspe.hhs.gov/daltcp/reports/astdev.htm

Full HTML Version: http://aspe.hhs.gov/daltcp/reports/astdev.pdf (54 PDF pages)

Consumer Choice and the Frontline Worker (1994)
(Article prepared for GENERATIONS, Fall 1994, Volume 18, Number 3, pages 65-70.)

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Deriving State-Level Estimates from Three National Surveys: A Statistical Assessment and State Tabulations (May 1998)
This report assesses the statistical issues involved in the production of state level estimates related to health and welfare issues from three national surveys: the Current Population Survey (CPS), the Survey of Income and Program Participation (SIPP), and the National Health Interview Survey (NHIS). With the devolution of many welfare programs from the Federal Government to the States, there is a strong interest in being able to track the health and welfare of the population in each State. This would allow for examination of the effect of various State welfare initiatives that are to be implemented in the next few years.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/derives.htm

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Estimating the Prevalence of Long-Term Disability for an Aging Society (April 1991)
This study was designed to provide comprehensive information about future long-term care needs in the U.S. Using data from the U.S. Decennial Census of Population and Housing, National Long-Term Care Survey and National Nursing Home Survey, the study developed detailed projections of the need for long-term care among the elderly in the years 2000, 2020 and 2040. Estimates of long-term care needs have traditionally relied on static models which assume that mortality and morbidity rates will remain constant over the projection period. This study employs a dynamic projection model. Three different sets of projections were estimated based on varying assumptions about changes in life expectancy and rates of impairment.

Report HTML Version: http://aspe.hhs.gov/daltcp/reports/agsoces.htm

Report PDF Version: http://aspe.hhs.gov/daltcp/reports/agsoces.pdf (23 PDF pages)

Technical Documentation HTML Version: http://aspe.hhs.gov/daltcp/reports/agsocestd.htm

Technical Documentation PDF Version: http://aspe.hhs.gov/daltcp/reports/agsocestd.pdf (54 PDF pages)

Federal Authority for Medicaid Special Needs Plans and their Relationship to State Medicaid Programs (January 2009)
This Brief reviews the history and current status of federal special needs plans (SNPs) authority, with particular attention to provisions of interest to state Medicaid programs that have or are considering entering into contracts with SNPs to integrate or coordinate Medicaid long-term care services with Medicare primary, acute and prescription drug services for dually eligible beneficiaries. SNPs have been promoted as a "mainstream" vehicle for integrating Medicare and Medicaid services, but to date, most SNPs have had no formal relationships with state Medicaid programs. In the future, SNPs proposing to serve dually eligible beneficiaries will be required to have contracts with state Medicaid programs. This and other key changes to the program are outlined in this Brief.

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Federal Programs for Persons with Disabilities (January 1990)
This report provides an overview of the major federal assistance programs targeted on non-elderly persons with disabilities. Program descriptions include expenditures, trends, the number and characteristics of recipients, eligibility rules, recent program history and legislative changes, and interactions with other federal programs. These programs contained in the report include: Social Security Disability Insurance, Supplemental Security Income, disability programs from the Department of Veteran's Affairs, Medicare, Medicaid, Department of Veteran's Affairs health services program, the Administration on Developmental Disabilities program, and programs from the Department of Education.

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Frontline Supervisor Survey Data Collection Report (July 2008)
To develop an evidence base for high-quality supervision in long-term care to inform policy, ASPE funded a survey of supervisors from provider organizations participating in the Better Jobs Better Care demonstration. The survey of supervisors contributes to better understanding the nature and influence of long-term care supervision on the stability of the direct care workforce by describing the supervisors' responsibilities and characteristics and comparing them across settings. This report discusses the survey instrument and data collected.

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Frontline Supervisor Survey Instrument Report (August 2005)
This report describes the processes that the contractor undertook to develop the data collection procedures for the frontline supervisor survey. These processes include: identifying our target group; collecting contact information for frontline supervisors; testing and revising the survey instrument; and specifying how the domains that are measured in the data collection will be relevant to the analysis of the direct care worker workforce and the improvement of direct care worker jobs.

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Frontline Supervisor Survey Report (September 2008)
To develop an evidence base for high-quality supervision in long-term care to inform policy, ASPE funded a survey of supervisors from provider organizations participating in the Better Jobs Better Care demonstration. The survey of supervisors contributes to better understanding the nature and influence of long-term care supervision on the stability of the direct care workforce by describing the supervisors' responsibilities and characteristics and comparing them across settings. This report addresses three sets of questions: (1) What are supervisors' roles and responsibilities? How do they differ across settings? (2) What are the characteristics of supervisors? How do they assess their jobs? Do they differ across settings? (3) Do supervisors and clinical managers agree about management practices where they work?

Executive Summary: http://aspe.hhs.gov/daltcp/reports/2008/FSSrptes.htm

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High Service or High Privacy Assisted Living Facilities, Their Residents and Staff: Results from a National Survey (November 2000)
This report gives a description of the policies and practices, residents, and staff in the segment of the assisted living facility (ALF) industry that provides the highest level of services and privacy. It reports data on a nationally representative sample of residents and staff in ALFs classified as providing relatively high services or offering a high privacy environment. These facilities, which comprise about two-fifths (41%) of the places calling themselves assisted living, were selected for more extensive and in-depth data collection because they seemed to most effectively exhibit key elements of the philosophy of assisted living.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/hshpes.htm

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Home Modifications: Use, Cost, and Interactions with Functioning Among Near-Elderly and Older Adults (October 2008)
This report analyzes new data from an experimental module to the 2006 Health and Retirement Study on assistive home features for near-elderly and older adults. In 2006, two-thirds of the population born in 1953 or earlier (ages 52 and older) had one or more assistive home features, about one-third added at least one of these features, and 40% used at least one feature in the last 30 days. The most common assistive home features included railings at the home entrance (36.2%), followed by grab bars in shower/tub (30.3%) and a seat for the shower/tub (27.3%). Among those who added features, roughly 9% reported no out-of-pocket payments, one-third less than $100, another third from $100 up to $500, 10% from $500 up to $1000 and the remaining 10% over $1000. Only 6% of respondents who added features could not reported an amount in broad brackets. A very low percentage--about 6%--reported that insurance or government programs paid some of the cost. In logistic regression models that included demographic, economic, health, and housing-related factors, significant predictors (direction of association by outcome shown parenthetically) included: age (+existence, +addition, +use), having another adult in the household (-use), home ownership (+addition), Medicare DI (+existence, +addition, +use), and long-term care insurance (+existence). Few health-related factors predicted the existence or addition of assistive home features; however, respondents with high blood pressure, diabetes, cancer, and lower body limitations were more likely to use such features. One in four near-elderly and older adults is at risk for a home modification, that is, has a mobility limitation and an unmodified barrier at the entry to their home, inside their home, or in the bathroom (either shower/bath area or toilet area). Adults receiving Medicare through the Disability Insurance program have elevated chances of being at risk for a home modification. Findings offer policy makers several new insights into the role of assistive home features in the daily lives of near-elderly and older adults.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/2008/homemodes.htm

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Last Thoughts: Beliefs Shape Expectations (1999)
This article is excerpted from the speech "Lifelong Wellness and Disability" (November 1998). It discusses how those with a disability could strive for good health. (Window on Wellness, Spring 1999, page 19).

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Literature Review and Synthesis: Existing Surveys on Health Information Technology, Including Surveys on Health Information Technology in Nursing Homes and Home Health (February 2009)
In an effort to better understand the adoption and use rates of electronic health records (EHRs) and other health information technology (HIT) applications in nursing homes and home health agencies, the University of Colorado was contracted to: (i) review the literature on surveys on adoption, use, and barriers to HIT adoption and use by nursing homes and home health agencies, and compare these surveys with surveys on HIT adoption by physician offices and hospitals; and (ii) develop survey instruments that could be used to gather information about HIT adoption and use in nursing homes, and barriers to adoption and use in nursing homes. Although numerous survey instruments have been fielded to assess HIT use in nursing homes and home health agencies, the lack of consistent definitions, terminology, item construction, sampling frames, and measurement criteria render it difficult to accurately gauge current HIT adoption rates. In this report, the authors review existing surveys for long-term care and other provider settings pertaining to current HIT use and adoption, barriers to adoption, and recommend issues to consider when developing survey questions for future surveys on HIT adoption, use, and barriers to adoption and use in nursing homes. A follow-up report will recommend survey questions that could be used in future surveys to gather information on HIT adoption, use, and barriers to adoption and use in nursing homes.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/2009/HITlitreves.htm

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Managed Care for People With Disabilities Research Inventory (February 1996)
This research inventory was assembled in preparation for the National Conference on Managed Care for People with Disabilities. It provides information on research projects on several distinct subpopulations of people with disabilities, including: (1) people with AIDS; (2) children with special health needs; (3) people with mental illness; (4) people with mental retardation or developmental disabilities; (5) frail elders; (6) people with chronic care conditions; and (7) people with disabilities as a whole. For each research project, the inventory provides information on the name of the study; a contact person; sponsoring organization; project director; funding source; project dates; research questions and goals; program descriptions; methods and data; and availability of results.

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Measuring the Activities of Daily Living: Comparisons Across National Surveys (1990)
The activities of daily living (ADLs) are the basic tasks of everyday life. Reported estimates of the size of the elderly population with ADL disabilities differ substantially across national surveys. Differences in which ADL items are being measured and in what constitutes a disability account for much of the variation. Other likely explanations are differences in sample design, sample size, survey methodology, and age structure of the population to which the sample refers. When essentially equivalent ADL measures are compared, estimates for the community-based population vary by up to 3.1 percentage points; and for the institutionalized population, with the exception of toileting, by no more than 3.2 percentage points. As small as these differences are in absolute terms, they can be large in percent differences across surveys. This article describes 11 recent surveys and how their ADL differences can effect policy analysis. (Journal of Gerontology: SOCIAL SCIENCES, November 1990, Volume 45, Number 6, Pages S229-237)

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National Study of Assisted Living for the Frail Elderly: Literature Review Update (February 1996)
In 1992, Lewin-VHI produced the report Policy Synthesis on Assisted Living for the Frail Elderly in order to address: the policy concerns generated by a growing frail elderly population, rapid increases in costs of care, and growing interest in various types of supportive housing for the elderly. The 1992 Policy Synthesis was based on a review and analysis of over 350 books, reports, documents (both published and unpublished), and telephone interviews with related association representatives, policymakers, academics, and researchers. The 350 items in the 1992 bibliography span 15 years and include material on a wide range of housing options for the frail elderly. This literature review update identified 175 articles and reports related to assisted living which represent a voluminous increase in the number of articles and books published specifically on the topic in the years since the 1992 policy synthesis was produced. Furthermore, while most of the 1992 literature was indirectly related to assisted living, most of the literature included in the update is directly related to the topic. To assemble the literature review update, an automated search of seven data bases was conducted. In addition, automated searches were conducted by specifying the names of publications that are known to feature articles on assisted living. The literature review update reveals a heightened interest in assisted living, with a more specific and exhaustive focus. Much of the literature has been inspired by opportunities for HUD Section 232 financing and Medicaid waivers. The needs of dementia patients and best practices research on living arrangements for the frail elderly are also frequent research topics. However, the literature appears to show that definitions of assisted living and its attendant services and amenities continue to be lacking.

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Nursing Home Work Practices and Nursing Assistants' Job Satisfaction (April 2009)
This article estimates the impact of wages, working conditions, and other aspects of job design on overall job satisfaction of certified nursing assistants working in nursing homes. Data are responses to the 2004 National Nursing Assistant Survey, responses by the certified nursing assistants' employers to the 2004 National Nursing Home Survey, and county-level data from the Area Resource File. Ordered logistic regression was used to estimate effects of variables reflecting working conditions, personal characteristics, and local labor market characteristics on certified nursing assistants' overall job satisfaction. Wages, benefits, and job demands, measured by the ratio of certified nursing assistant hours per resident day, were associated with job satisfaction. Consistent with previous smaller studies, strong associations with job satisfaction were found for indicators that certified nursing assistants felt respected and valued by their employers and had good relationships with supervisors. Certified nursing assistants were also more satisfied when they reported that they had enough time to complete their work, that their work was challenging, that they were not subject to mandatory overtime, and when a labor union represented certified nursing assistants in their nursing home. This is the first investigation of certified nursing assistant job satisfaction using a nationally representative sample of certified nursing assistants matched to information about their employing nursing homes. The findings corroborate results of smaller, less representative studies in showing that compensation and working conditions that provide respect, good relationships with supervisors, and better staffing levels are important to certified nursing assistant job satisfaction.

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Paying the Bill (1998)
Financing assisted living costs is most often determined in the weeks before an individual moves into a facility. Making plans now can result in saved dollars and fewer headaches. (Assisted Living Today, July/August 1998, Volume 5, Number 4, pages 39-41)

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Private Long-Term Care Insurance: Following an Admission Cohort over 28 Months to Track Claim Experience, Service Use and Transitions (April 2008)
This is the third in a series of reports based on longitudinal information collected from a sample of 1,474 individuals with long-term care (LTC) insurance, who notified their insurance company that they were receiving or intended to receive paid services for which they filed, or would be filing, a claim under their LTC policy. These individuals comprise "an admissions cohort" of new LTC service users. This admissions cohort has been tracked over a period of 28 months. Every four months after the initial in-person baseline interview, these individuals were contacted and completed a telephonic assessment that focused on changes in disability status, service settings, preferences, experience with the claims filing process, use of care management services and service setting transitions. The purpose of this report is to present findings from the analysis of longitudinal data collected over this 2½ year period. The authors also report on individuals' satisfaction with providers and their experiences with their LTC insurance.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/2008/coht28moes.htm

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Psychiatric Boarding Interview Summary (January 2009)
ASPE contracted with The Lewin Group to conduct interviews regarding boarding of psychiatric patients in the Emergency Department (ED). The goal of the interviews was to gain the perspective of ED Directors/ED Physicians, Department of Psychiatry Chairs/on-call Psychiatrists, and Nurse Case Managers/Social Workers in nine hospitals. Where possible, The Lewin Group also interviewed community stakeholders of the hospitals. These stakeholders were from community mental health centers, state facilities, and state mental health departments. This paper is a summary of the 28 interviews.

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Reliability and Validity of the National Incidence of Child Abuse and Neglect Study Conducted by Westat Associates in 1988: Methodological Review (August 1989)
This report summarizes a methodological review of the 1988 National Incidence of Child Abuse and Neglect Study (NIS-2) and highlights the review's implications. The review includes an analysis by two expert statisticians concerning the validity of NIS-2 and the reliability of its results, alternative explanations of the data posed by several child abuse researchers and policymakers, and a secondary analysis of the NIS-2 data which determines its utility to address key policy and program issues. The report identifies a number of possible problems with NIS-2 and recommends ways to increase the accuracy and effectiveness of future studies on child maltreatment.

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Searching for a Needle in a Haystack: Creative Use of the Decennial Census Dress Rehearsal Data to Find Board and Care Places in Central Missouri (February 1992)
The purpose of this survey was to determine: (1) whether the Census provides a suitable frame for selecting board and care places; and (2) whether the questionnaire would elicit sufficient information to identify such places. Board and care places are housing units or group quarters which provide room, meals and one or more services to dependent persons. The services center on activities of daily living or instrumental activities of daily living. They can be as concrete as assisting the dependent person with eating or as abstract as providing protective oversight.

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Service Utilization and the Individual, Family, and Neighborhood Characteristics of Children with Disabilities in Illinois: Final Report (September 1996)
This report describes the demographic characteristics and human services utilization of all children and adolescents who are identified as having a disability in Illinois. It also seeks to understand the stability of care that these children receive through childhood and adolescence. The database used for the study, the Integrated Database on Children's Services in Illinois (DB), was developed from Statewide service data which came from a set of agencies including the Department of Public Aid, the Illinois State Board of Education, and the Department of Mental Health and Developmental Disabilities. The study focuses on those children identified as having a disability from July 1, 1989 through June 30, 1994. The report finds that the population of children served by public programs for disabilities in Illinois grew and changed dramatically between Fiscal Year (FY) 1990 and FY 1994: the Supreme Court's Zebley decision allowed more children with emotional disorders to receive services and the Medicaid program expanded to address the needs of children with extreme emotional disturbances; (2) the new population of children receiving Supplemental Security Income (SSI) is slow to use additional services; (3) the population of children receiving special education services is dropping as mainstreaming disabled children into regular classrooms becomes more prevalent; and (4) children with less severe conditions, such as language disorders or learning disabilities, are less likely to participate in multiple programs than children with more severe or chronic disabilities, like severe emotional disturbance. The report concludes this study could be used as a baseline against which to measure changes occurring as a result of 1996 changes to SSI eligibility criteria and future changes in Medicaid and welfare programs. It notes that a possible addition to the analysis would examine new early intervention programs.

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Source Book on Long-Term Care Data (July 1983)
Tables in this report were prepared in response to a contractual charge to analyze existing data sources for answers to as many long-term care questions as data and resources would permit. More than two dozen research papers containing roughly 500 tables were produced as a result of that effort. This report contains a substantial portion of those tables.

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State Long-Term Care Partnership Insurer Report Requirements (January 28, 2008; revised January 21, 2009, revised October 2, 2009)
This paper outlines the specific data elements that long-term care insurance participating in a State Partnership for Long-Term Care must provide to the Department of Health and Human Services (HHS). This system of records is required by the Deficit Reduction Act of 2005. Federal regulations supporting these data requirements were published in the Federal Register on December 18, 2008. The data include variables on Partnership policy features such as the amount of the daily benefit and the type of inflation protection purchased. Also included in the data set are variables on the insurance benefits used under the policy. Once processed by HHS, these data are shared with the relevant participating state Partnership staffs.

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The Impact of Disability Trends on Medicare Spending (September 2005)
The purpose of this study is to better understand the relationship between disability declines and Medicare costs and what Medicare spending patterns may suggest about the relationship between disability and health. To that end, the study examines actual patterns of Medicare spending and utilization that occurred over the period of declining disability between 1984 and 1999 and how they differ from what might have been expected had disability not changed. Spending is examined in the aggregate, by service, and by type of disability, and implications for the relationship between disability, Medicare spending, and health are discussed. Based on the results, Medicare spending projections are developed under various assumptions about how disability and spending are likely to change over the over the next several years.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/distrndes.htm

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The National Nursing Assistant Survey: Improving the Evidence Base for Policy Initiatives to Strengthen the Certified Nursing Assistant Workforce (April 2009)
This study introduces the first National Nursing Assistant Survey (NNAS), a major advance in the data available about certified nursing assistants (CNAs) and a rich resource for evidence-based policy, practice, and applied research initiatives. We highlight potential uses of this new survey using select population estimates as examples of how the NNAS can be used to inform new policy directions. The NNAS is a nationally representative survey of 3,017 CNAs working in nursing homes, who were interviewed by phone in 2004-2005. Key survey components are recruitment; education; training and licensure; job history; family life; management and supervision; client relations; organizational commitment and job satisfaction; workplace environment; work-related injuries; and demographics. One in three CNAs received some kind of means-tested public assistance. More than half of CNAs incurred at least 1 work-related injury within the past year and almost one-quarter were unable to work for at least 1 day due to the injury. Forty-two percent of uninsured CNAs cite not participating in their employer-sponsored insurance plan because they could not afford the plan. Years of experience do not translate into higher wages; CNAs with 10 or more years of experience averaged just $2/hr more than aides who started working in the field less than 1 year ago. This study can be used to understand CNA workforce issues and challenges and to plan for sustainable solutions to stabilize this workforce. The NNAS can be linked to other existing data sets to examine more comprehensive and complex relationships among CNA, facility, resident, and community characteristics, thereby expanding its usefulness. (The Gerontologist 2009, 49(2):185-197; doi:10.1093/geront/gnp024)

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The Pennhurst Longitudinal Study: Combined Reports of Five Years of Research and Analysis (March 1985)
The Pennhurst Longitudinal Study was a five year, in-depth review of the effects of the court-ordered deinstitutionalization of Pennhurst residents. Its aim was to provide federal and state officials and others with information to make better policy decisions regarding the processes related to the deinstitutionalization which is underway in many parts of the country. Federal planners, recognizing the significance for clients, families, communities, and state of Judge Broderick's and other similar actions, decided in 1979 to launch this five year study. This project was unique in several respects. It yielded considerable information which is not only valuable to other researchers, but also instructive to legislators, judges, and federal, state and local program administrators and policymakers.

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The Role of Home and Community-Based Services in Meeting the Health Care Needs of People with AIDS: Final Report (March 1998)
This is the final report for the project, "Role of Home and Community Based Services in Meeting the Health Care Needs of People with AIDS," conducted by Mathematica Policy Research, Inc. for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE). The goal of the project was to assist ASPE in developing a research agenda for studying home and community based service use among people with AIDS. The project had three components: (1) a review of the recent literature describing the delivery and financing of home and community based services for people with AIDS; (2) case studies of service provision in New York City and Los Angeles; and (3) an analysis of use and reimbursement patterns for New Jersey Medicaid beneficiaries with AIDS (conducted by the AIDS Research Group of the Institute for Health, Health Care Policy, and Aging Research at Rutgers University).

Executive Summary: http://aspe.hhs.gov/daltcp/reports/aidsfres.htm

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The Use, Cost, and Economic Burden of Nursing Home Care in 1985 (January 1989)
This study uses the 1985 National Nursing Home Survey to examine the use and cost of nursing home care among the elderly population of the U.S. The following questions are addressed: How many persons aged 65+ use nursing homes in a given year? How do they stay and what are their annual charges? How often, and to what extent, do residents "spenddown" to Medicaid? How much of the annual charges are paid by the various payers; in particular, what are annual out-of-pocket costs? The study found that approximately 2.1 million persons age 65+ (7.5% of the U.S. elderly population) spent some time in a nursing home during 1985. Over 70% were women and nearly two-thirds were single, widowed or divorced women. Mean charges per nursing home user in 1985 were $9,600 and median charges were $7,700. About 53% of 1985 nursing home costs were paid privately, out-of-pocket, 35% by Medicaid, 8% by Medicare, and 4% by other sources. About 22% of nursing home residents who initially entered as private pay patients became eligible for Medicaid during their stay.

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Understanding the Costs and Benefits of Health Information Technology in Nursing Homes and Home Health Agencies: Case Study Findings (June 2009)
This study adds to the growing body of literature through case studies reporting benefits and costs/burdens in eight sites with advanced health information technology (HIT) systems. While all eight of the case study sites noted that they would "never go back" to paper?based systems for administration and clinical service delivery, no site had conducted a rigorous cost?benefit analysis of their HIT systems. Thus, the case studies necessarily focused on the costs and benefits reported by system users and managers. Respondents cited numerous examples of system benefits and rated their magnitude, as well as identified the types of increased costs and burdens resulting from HIT implementation.

Executive Summary: http://aspe.hhs.gov/daltcp/reports/2009/HITcsfes.htm

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Variations in the Medicaid Safety Net for Children and Youth with High Medical Costs: A Comparison of Four States (November 1990)
This report analyzes the Medicaid experience of children and young adults with total annual Medicaid claims of $25,000 or more in California, Georgia, Michigan and Tennessee in order to better understand service utilization patterns and how they vary by age and other characteristics. An important part of the study involved analysis of the eligibility pathways through which the children became enrolled in Medicaid.

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Why Do They Stay? Job Tenure Among Certified Nursing Assistants in Nursing Homes (April 2009)
This study identifies factors related to job tenure among certified nursing assistants (CNAs) working in nursing homes. The study uses 2004 data from the National Nursing Home Survey, the National Nursing Assistant Survey, and the Area Resource File. OLS regression analyses were conducted with length of job tenure as the dependent variable. Tenure of CNAs was hypothesized to be motivated by the extrinsic rewards of their job; initial training and mentoring; reasons for being a CNA; organizational culture; and personal, facility, and market characteristics. Separate analyses were conducted for the overall sample and for CNAs who worked for the facility for more than one year. Among policy-relevant domains, extrinsic rewards had the largest number of significant variables (four). Only one training and one organizational culture variable significantly affected CNA job tenure. Significant variables in domains not readily influenced by policy (e.g., personal characteristics and characteristics of the facility and surrounding market area) were often significant in both regressions. This study underscores the importance of the basic economics of job choice by low-income workers. Wages, fringe benefits, job security, and alternative choices of employment are important determinants of job tenure that should be addressed, in addition to training and organizational culture. (The Gerontologist 2009, 49(2):198-210; doi:10.1093/geront/gnp027)

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Work, Welfare, and the Burden of Disability: Caring for Special Needs of Children in Poor Families (April 1996)
This paper addresses issues which arise at the juncture of welfare and disability policies. Using preliminary data from a recent survey of current and recent AFDC recipients in California, we find that disabilities and chronic health problems affect the mothers or children in 43% of all households in the AFDC system. The presence of one or more children with disabilities or chronic illnesses is found to have an impact on the economic well being of families, with increased levels of direct hardship reported by families caring for one or more severely impaired children. Potential causes of higher levels of hardship are examined by considering the impact of direct expenses associated with the care of the child(ren) and reductions in the mother's probability of paid employment. SSI receipt is found to have a modest antipoverty effect for families with special needs children, reducing the prevalence of poverty and extreme poverty for families even after the additional direct costs of caring for these children are considered.

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Writing the Check (1999)
This article discusses the different ways the public pays for long-term care services. It also discusses purchasing long-term care insurance. (Assisted Living Today, July/August 1999, Volume 6, Number 6, pages 36-39)

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