Service Use and Transitions: Decisions, Choices and Care Management among an Admissions Cohort of Privately Insured Disabled Elders. B. Functional and Cognitive Characteristics


As part of the baseline interview, the trained nurses assessed the functional and cognitive status of the claimants, as well as collected information on medical diagnoses. This included questions on Katz’s ADL scale and Lawton’s scale of IADL. ADLs included bathing, dressing, toileting, transferring, eating and continence. IADLs included housework, laundry, meal preparation, shopping for groceries, managing money, using the telephone, transportation and medication management.4 The nurses also administered the Short Portable Mental Status Questionnaire (SPMSQ) -- a standard test designed to detect dementia.5Table 3 highlights the functional and cognitive profile of people in each service setting. Figure 5 summarizes key findings in graphic form.

TABLE 3: Functional and Cognitive Characteristics of Admission Cohort by Service Setting
Health Characteristics Receiving Paid Care at Home
Nursing Home
Assisted Living
Person Not Yet Receiving Paid Care
ADL Limitations
   Under 2 ADL limitations 18% 12% 36% AB 34% AB
   2 ADL limitations 18% 11% 19% 12%
   3-4 ADL limitations 34% BC 20% 25% 31% B
   5-6 ADL limitations 30% CD 57% ACD 20% 22%
IADL Limitations
   Under 5 IADL limitations 8% 7% 7% 20% ABC
   5-6 IADL limitations 43% BC 8% 20% B 41% BC
   7-8 IADL limitations 49% 85% ACD 73% AD 39%
Mobility -- Inside Limitation
   Yes 52% 78% ACD 45% 43%
   No 49% B 22% 55% B 57% B
Mobility -- Outside Limitation
   Yes 87% D 96% ACD 82% 74%
   No 14% B 4% 18% B 26% AB
Cognitive Impairment
   Yes 28% 64% AD 63% AD 29%
   No 72% BC 36% 37% 71% BC
Use of Assistive Technology
   Yes 86% CD 88% CD 77% 74%
   No 14% 12% 23% AB 26% AB


FIGURE 5: Average Number of Functional Limitations by Service Setting: ADLs and IADLs

Functional Limitations

As expected, those receiving paid care in a nursing home are the most disabled in their ADLs, with an average of 4.2 limitations. It is important to note that participants were asked if they were able to perform an activity independently, with partial assistance or with total assistance. Those who reported that they were anything other than independent are considered to have a limitation in an ADL. Those living at home and currently receiving paid services have more ADL limitations than both those in ALFs and those not yet receiving paid care. It is also interesting to note that those living in ALFs and those living at home but not yet receiving paid care, are most likely to have fewer than two ADL limitations.

In terms of IADL limitations, those in assisted living and in nursing homes have significantly more limitations than those living at home. Moreover, of those who are living at home, the ones who are currently receiving paid care have more IADL limitations than do those who have not yet commenced service use. In terms of total limitations, the most physically disabled are those in nursing homes, followed by those receiving paid care at home, then by ALF residents. Individuals, who have not yet begun to use formal paid care, are the least disabled. Taken together, these findings suggest that individuals entering ALFs are doing so in large part to compensate for deficiencies in IADLs -- which are also related to dementia status -- whereas those receiving care at home, are more often receiving services to compensate for purely physical disabilities.

Cognitive Limitations

A high proportion of those living in nursing homes and ALFs are cognitively impaired -- close to two-thirds in each setting. While it is not surprising that this percentage is higher than it is for claimants living in the community, it is somewhat unanticipated that the proportion is so high for claimants choosing ALFs. This undoubtedly reflects the fact that most people prefer to be in a home like setting and in response, ALFs are providing more services -- including dementia care. It supports the trend in caregiving away from the more “medical” nursing home toward the more “home-like” ALF. Also, the fact that the rate of cognitive impairment is relatively low among home care claimants suggests that, in the home, both formal and family caregivers are much more adept or able to deal with physical limitations than they are with dementia-related limitations. The latter often requires more intensive and ongoing monitoring than the former, which is often confined to providing assistance with a discrete number of tasks during the course of a day.

HIPAA Triggers and Service Setting

In the Health Insurance Portability and Accountability Act (HIPAA) of 1996 legislation, LTC insurance policies are tax qualified if access to benefits is limited to: (1) individuals with at least two ADL limitations; or (2) individuals who are moderately or severely cognitive impaired. Figure 6 shows that there is variation across service settings. The highest proportion of those meeting triggers live in nursing homes, which is to be expected given that they are the most disabled. But still, 6% here do not meet HIPAA triggers. Seventeen percent of policyholders living in assisted living do not meet these triggers. It is important when viewing these percentages to keep in mind that not all of these insureds will become claimants -- something we will know in the future as we obtain data from the telephone interviews and claims data from the insurance companies. Three out of four people living at home without current paid care meet the HIPAA eligibility triggers. These individuals have the highest proportion among the service settings of those who do not meet triggers (14%) indicating that they may be planners (notifying their insurance companies early to make sure they know what to do if they become more disabled and want to file a claim) or they may be unaware of their policy benefit eligibility triggers or perhaps they are particularly frail and cannot continue to function independently in their own homes. It is also possible that the policies held by these claimants do not use the HIPAA triggers (they may have medical necessity or doctor certification as their benefit eligibility requirement). Over time, we will better understand who these people are and whether they were able to obtain benefits under their policies and if and how they continued to use paid care over time. The administrative data we obtain from the insurance companies will also tell us whether or not a person’s policy requires HIPAA triggers be met for benefit eligibility.

FIGURE 6: Percent Meeting HIPAA Triggers by Service Setting

Use of Assistive Technology

We asked participants if they were using equipment to complete their ADLs and a majority in all settings indicated that they were. Although the percentage using such equipment is higher at home and in the nursing home, more than three-quarters of the insured’s in all of the service settings indicated that they were using some form of assistive technology.6

To sum up, those newly residing in nursing homes are the most dependent in terms of ADL and IADL limitation and cognitive impairment, while those living at home but not yet receiving paid care are the least dependent. These less disabled individuals appear to recognize their decline and are contacting their insurance company early. Alternatively, they may be more likely to have progressive health loss instead of a significant acute episode that requires immediate and urgent care.

View full report


"admcohort.pdf" (pdf, 1.33Mb)

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®