Prospective Outcomes of Informal and Formal Home Care: Mortality and Institutionalization. SECTION 1: OVERVIEW AND SIGNIFICANCE


Use of nursing home care is typically a last resort for both the disabled elderly individual and the individual's family (Stone et al., 1987; Doty, 1986; Soldo and Manton, 1985; Dunlop, 1980). Attempts to substitute formal home-based care consisting of skilled nursing and personal care, homemaking, and chore services for nursing home care have been disappointing. Higher costs associated with use of formal services, with little or no offsetting reduction in nursing home admissions, reflect largely additional services provided to persons who would not have entered a nursing home even in the absence of the in-home services program (Thornton et al., 1988; Kemper et al., 1987; Weissert, 1986; 1985). Hughes et al. (1987) did find that in-home services reduce use of lighter care nursing homes. Branch et al. (1988) found that the key predictors of nursing home admissions are quite different from those for use of medical home care.

To date, however, home-based care has been evaluated only broadly, with little attention to potential variability in outcomes according to specific caregiving arrangements. A very small number of studies have attempted to assess differences in outcomes among experimental subpopulations, but these efforts have been inconsistent and plagued by small sample sizes (Kemper et al. 1987). Probably the most careful analysis of differential impacts on subpopulations was carried out in the evaluation of the Channeling Demonstration. Overall, impacts did not vary by subpopulation in any clear cut pattern.

Theory, notably by Litwak (1985), suggests that some sources of caregiving or combinations of caregiving sources may work better than others. Staging theories of health care utilization imply that if informal support or care were available, ill persons would seldom reach formal care. Applied to a very old, disabled population, however, this theory would predict at best only a delay in formal care use rather than its prevention. Extended further, this line of reasoning also would predict postponement of death for those with informal care.

The specific aim of the study reported here is to determine whether home-based care, when provided by certain types of caregivers or by particular combinations of caregiver types, is more efficacious than other home-based care arrangements in preventing or delaying mortality and admission to a nursing home for elderly persons with dependencies in activities of daily living. The comparison groups examined include functionally impaired elderly receiving help vs. no help, paid vs. unpaid help, and help from immediate family vs. help from more distant relatives or nonrelatives, as well as help from paid and unpaid sources vs. help from unpaid sources alone. If some caregiving arrangements rather than others result in improved outcomes, policy makers will be in a better position to target resources for home-based care where those more effective arrangements exist or can be created.

The analyses relied on data from the Longitudinal Study of Aging, consisting of elderly aged 70 years and older, living in the community, originally interviewed in 1984, and followed through 1986. Outcomes derive from linkages to the National Death Index (mortality) and the Medicare Part A data (nursing home admissions). Statistical methods appropriate to a prospective cohort design are used to analyze the data, viz., survival analysis and logistic regression of dichotomous outcomes.

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