A Report on the Actuarial, Marketing, and Legal Analyses of the CLASS Program. C. Use of Long-Term Services and Supports by Older People with Cognitive Impairment and People with Dementia

10/14/2011

Older people with cognitive impairment and people with dementia are high users of residential long-term care services. In 2009, 47 percent of all nursing home residents had a diagnosis of dementia in their nursing home record (American Health Care Association, 2009), and 68 percent had some degree of cognitive impairment (USDHHS, 2010). Virtually all studies of risk factors for nursing home placement that have been conducted in the United States over the past 30 years and have measured either cognitive impairment or dementia have found that they are strong predictors of placement (see, e.g.,Banaszak-Holl et al., 2004; Bauer et al., 1996; Bharucha et al., 2004; Black et al., 1999; Branch et al. 1982; Freedman et al., 1996; Greener et al., 1995; Jetteet al., 1995; Salive et al., 1993; Shapiro et al., 1988; Temkin-Bauer 1995; Weissertet al., 1990; Wolinsky et al., 1993).

Older people with cognitive impairment and people with dementia also constitute about half of all residents of assisted living facilities (45%-67% according to a recent report) (Hyde et al., 2007). Moreover, the proportion seems to be growing as assisted living facilities increase their capacity to serve and their marketing to such people and their families.

These findings are consistent with the findings from the ASPE-funded study, described earlier, of a sample of 1,474 individuals who had long-term care insurance and had just begun or were about to begin using paid long-term services and supports. In that sample, 64 percent of the individuals who were receiving paid care in a nursing home and 63 percent of those who were receiving paid care in an assisted living facility were people with cognitive impairment (Cohen et al., 2006).

Despite the large proportions of nursing home and assisted living residents that are people with cognitive impairment and dementia, the majority of people with these conditions are living in the community at any point in time. Most of them receive substantial amounts of help from family members and other unpaid caregivers, but they are also high users of home and community-based long-term care services and supports. One study of community-living older people who needed help to perform ADLs and IADLs found that those who had cognitive impairment were more than twice as likely as those who did not have cognitive impairment to receive paid home care Johnson and Weiner (2006). In addition, those who had cognitive impairment and received paid home care used almost twice as many hours of care monthly as those who did not have cognitive impairment.

It is sometimes said that older people with cognitive impairment and people with dementia generally do not receive Medicare- and Medicaid-funded home health care, but available data show that is not true. In 2004 and 2005, 36 percent of Medicare beneficiaries age 65 and older who received home health care services paid for by either Medicare or Medicaid were people with cognitive impairment (Murtaugh et al., 2009)

Older people with cognitive impairment and people with dementia are also high users of adult day services. One study of older people in adult day centers found that more than half had cognitive impairment or dementia (O’Keeffe and Siebenaler, 2006).

Lastly, available data from three states indicate that more than one-third of older people who receive Medicaid home and community-based waiver services are people with cognitive impairment and dementia (Fortinsky et al., 2004; Hirdes et al., 2004; Mitchell et al., 2006).

This high use of residential and home and community-based long-term services and supports reflects the high need among older people with cognitive impairment and people with dementia for help to perform daily activities and their need for supervision to avoid threats to health and safety. It is important in this context to note the finding of the ASPE-funded study of long-term care insurance policyholders that only 28 percent of policyholders who were receiving paid care at home were people with cognitive impairment, compared with the much higher proportions of people with cognitive impairment among policyholders who were receiving paid care in an assisted living facility or nursing home (63% and 64% respectively) (Cohen et al. (2006). Doty et al. (2010) point out that having long-term care insurance coverage reduces the importance of cost in decisions about where to receive paid care, thus allowing individuals and their families to choose the service setting that meets their needs. Thus, the higher proportions of policyholders with cognitive impairment among all policyholders receiving paid care in nursing homes and assisted living facilities speaks again to their high need for help to perform daily activities and their need for supervision to avoid threats to their health and safety.

From the perspective of families, the care needs of older people with cognitive impairment and people with dementia, and especially the need for supervision to avoid threats to health and safety, often result in high stress and burden. In several studies, more than half of the family caregivers of people with dementia have said they feel they have to be “on duty” 24 hours a day in order to anticipate and prevent problems and ensure the person’s safety (Mahoney et al., 2003; Schulz et al., 2003). This perceived need for 24-hour vigilance has been found in caregivers of people in all stages, including caregivers of people who are in the mild and moderate stages of dementia and may be at risk of wandering and getting lost or other unsafe activities (Adams et al., 2006).

View full report

Preview
Download

"index.pdf" (pdf, 350.5Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appA.pdf" (pdf, 150.08Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appB.pdf" (pdf, 548.14Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appC.pdf" (pdf, 150.56Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appD.pdf" (pdf, 318.45Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appE.pdf" (pdf, 319.19Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appF.pdf" (pdf, 155.03Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appG.pdf" (pdf, 181.05Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appGa.pdf" (pdf, 151.02Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appGb.pdf" (pdf, 123.12Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appH.pdf" (pdf, 256.35Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appI.pdf" (pdf, 358.34Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appJ.pdf" (pdf, 1.21Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appJa.pdf" (pdf, 396.06Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appJb.pdf" (pdf, 313.17Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appJc.pdf" (pdf, 252.71Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appJd.pdf" (pdf, 261.97Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appK.pdf" (pdf, 186.22Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appL.pdf" (pdf, 788.88Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appM.pdf" (pdf, 249.45Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appN.pdf" (pdf, 7.72Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appNa.pdf" (pdf, 208.04Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appNb.pdf" (pdf, 6.96Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appNc.pdf" (pdf, 622.02Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appNd.pdf" (pdf, 211.36Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appO.pdf" (pdf, 2.01Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appP.pdf" (pdf, 9.15Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appPa.pdf" (pdf, 233.71Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appPb.pdf" (pdf, 253Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appPc.pdf" (pdf, 546.97Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appPd.pdf" (pdf, 505.4Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appPe.pdf" (pdf, 462.21Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appQ.pdf" (pdf, 285.57Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"appR.pdf" (pdf, 797.76Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®