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


In order to better understand the decision-making process regarding service choice, we needed to obtain a picture of the amount of paid and unpaid care people were receiving, how long they had been receiving it and whether or not they were receiving any care prior to their current episode of care use.

First, we asked how long people had been receiving paid care related to a disability or a change in health status in their current setting. We structured the question so as to exclude paid care unrelated to limitations in ADLs and IADLs -- or care that may be more related to convenience instead of disability. Figure 7 shows that those receiving paid care at home have been receiving such care for the shortest amount of time -- less than one month. In contrast, individuals interviewed in residential care settings have been receiving care longer than those at home, but about the same as each other. Across all service settings the vast majority had been receiving paid care at their current location for less than three months. This timeframe is ideal when asking someone to recall why a decision was made, as well as for understanding satisfaction with service choices: it is close enough to the beginning of the process to be remembered easily, yet long enough for people to have had significant experience with the setting and provider to form an opinion about their care.

FIGURE 7: Length of Time Receiving Paid Care in Current Location

As noted earlier, we screened participants prior to the baseline interview to ensure that they were as close to the time that they began using paid care as possible. One of the criteria at screening was that they had to have begun using paid care within the last 120 days or four months; however, by the time the baseline interview occurred, a small percentage of the sample that may have had difficulty in scheduling the in-person interview had surpassed the four month requirement. No one had been using paid care in his or her current service setting for greater than six months.

We were interested in whether or not a person was receiving any formal LTC services or unpaid family care prior to entering their current service setting. Figure 8 shows the proportion of those currently receiving care that had received services (paid and/or unpaid) prior to entering the current service setting.

FIGURE 8: Prior use of Formal and Family Care by Service Setting

As shown, between 7% and 30% had accessed the formal LTC support system at some point before beginning their current paid care episode. Between one-half and two-thirds depended on unpaid family care prior to accessing paid services under the LTC insurance policies. Current nursing home residents were more likely to have received paid LTC care prior to entering the nursing home than current home care users, mostly in a hospital or at home from paid caregivers. Current ALF residents were the most likely to have received other LTC services prior to entering the ALF, most from paid caregivers in their home. This seems to suggest that those in facilities had tried to maintain their independence and remain at home with paid help, but that it may not have been enough. It is important to note, too that we did not ask when the prior care occurred. Current ALF residents were also more likely to have received unpaid care prior to entering the ALF than both current home care users and current nursing home residents. One quarter of those who are not currently receiving paid care, but expect to do so in the next two months stated that they recently received paid help (most either at home or in a rehab hospital). On the whole, current nursing home residents had been receiving their unpaid care the longest, with over half (56%) stating that they had been receiving unpaid care for more than two years prior to entering the nursing home.

In addition to prior service use, we asked participants in all service settings if they were currently receiving unpaid help specifically with ADLs and IADLs from family members or friends. Of particular interest was whether or not those residing in nursing homes were receiving more than just companionship care from their families. More specifically, it is often assumed that because someone resides in a nursing home, all of their care is provided by paid caregivers. Yet there is a great deal of anecdotal information suggesting that there are shortages of staff in nursing homes. Thus, we wished to determine if family members are providing personal care services in nursing homes.

Figure 9 shows the proportion of insured’s that are receiving unpaid help with everyday activities by service setting.

FIGURE 9: Currently Receiving Unpaid Care by Service Setting

Although significantly less than those living at home, a little more than one-third of current nursing home residents still receives unpaid help with daily activities from their family members and/or friends. The proportion of people living at home, but not yet receiving paid care, and who receive unpaid help is significantly higher than those in all other service settings, including paid home care recipients. One can conclude that once the family support system is strained or unable to provide sufficient care, policyholders begin to receive paid care to supplement their unpaid care. This why the percentage of individuals receiving unpaid care declines somewhat once formal care is put in place. Individuals living at home who have not yet begun to use paid services are also the least disabled. This data suggests that the amount of unpaid help received is not just a function of disability status but also a function of where you receive care.

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