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


Having gone through the decision-making process, how satisfied are participants with their choice of home care provider, nursing home or ALF? Have they chosen a care provider that meets their needs? ALF residents were more likely to investigate quality information -- are they more likely to be satisfied with their choice? We first asked if the care that participants were receiving was meeting their needs. Figure 27 shows that there is a very high level of met need across all three service settings. However, those receiving paid care at home are less likely to report that their care is meeting their needs than those in a nursing home or ALF.

FIGURE 27: Current Care is Meeting Needs

As stated previously, one of the most important reasons cited by those in facilities regarding their choice of care location was that they wanted to be guaranteed that if they needed a certain level of care, it would be available to them. Perhaps those receiving paid care at home are so determined to remain in their own homes, that they are willing to make a trade-off -- or perhaps satisfaction has less to do with care needs than other issues. A more detailed examination of specific satisfaction issues may shed some light on this. However, we first focus on the relationship between met needs and disability status.

FIGURE 28: Current Care Needs Are Being Met by Disability Status

The pattern observed above persists even when looking at satisfaction levels by disability status and cognitive impairment. The majority of claimants report that their current care needs are being met, regardless of disability level; however those living at home and receiving paid care are the least likely to say that the care they are receiving is meeting their needs. Of those home care recipients who say that their care needs are not being met, almost all of them indicated that they need additional help, either with ADLs, IADLs, respite care or overnight care.

We next asked participants in each service setting a general satisfaction question related to their choice of a particular nursing home, ALF or home care provider. This was followed by a series of more detailed questions. Figure 29 shows that for the most part, people in all service settings are at least somewhat satisfied with their decision to use their current provider. However, when looking at the distinction between very satisfied and somewhat satisfied, there is a noticeable difference. Those receiving paid care at home and in ALFs are more likely to state they are very satisfied with their decision than are those residing in nursing homes. This is interesting, particularly in light of the fact that home care recipients are more likely to report unmet need.

FIGURE 29: Overall Satisfaction with Specific Provider

To further understand satisfaction, we asked a series of questions related to specific issues people may encounter when receiving paid care. It is common to hear concerns among those receiving care at home that they feel uncomfortable with a “stranger” in their house or that they do not have enough privacy with someone around all the time. Given the current shortage of health professionals, are caregivers spending enough time with people? Questions were structured such that respondents could indicate whether an issue occurred always, sometimes or never. Figure 30 shows the proportion of those indicating an “always” response.

FIGURE 30: Satisfaction Measures by Care Setting

Again, overall there is a high level of agreement with these aspects of satisfaction across all service settings; however those in nursing homes are less likely to indicate that they have enough privacy, the staff spends enough time with them, the nursing home staff is reliable and that they provide quality care all the time. Home care recipients were the most satisfied with their caregivers across almost all measures, which would seem to indicate that satisfaction with a caregiver has little or no relationship to whether or not you feel your care needs are being met.

We completed further analyses of reports of unmet need to see if service setting actually made a difference in terms of indicating whether or not care needs are being met. We held all other variables constant (using regression analysis) so that we could find out what was having an independent effect on reported unmet need. The analysis showed that in fact, being a home care recipient is associated with unmet need, as well as reporting that the caregiver(s) do not spend enough time with the claimant, and not feeling safe with the caregiver all the time. This means that, holding all other variables that could potentially have an effect on unmet need constant, claimants were more likely to report that their care needs were not being met if they were receiving paid care at home.

It is noteworthy that across all service settings, nearly one in five respondents felt that the staff did not spend enough time with them. Given that the nature of the service provided is personal care, this finding raises concerns. A question that arises is whether individuals with more needs are more likely to feel this way compared to those with less needs. As well, we are interested to know whether there are certain characteristics associated with citing one of these quality measures as lacking. Table 5 highlights the relationship between selected socio-demographic characteristics and aspects of provider quality.

It does appear that those the more ADL limitations one has, the less likely they are to indicate that the staff/caregiver spends an adequate amount of time with them. The same holds true for the other measures -- as disability increases, a person is less likely to indicate that the staff provides high quality care or that they are reliable. Measures do go back up for those with cognitive impairment that have proxies responding on their behalf. In terms of age, older service users are the more likely to indicate that staff provide quality care and that they are reliable; but less likely to report that they always spend enough time. Married individuals and those without children are more likely to indicate that staff spend enough time with them.

Among paid home care recipients we were interested in determining whether or not their caregiver was from an agency or individually hired. We found that about a third (32%) of paid home care recipients’ caregivers were not from an agency. We also asked those who hired caregivers from an agency whether or not the agency sends the same caregiver consistently. In 77% of the cases, recipients reported the agency always sends the same caregiver and in another 21%, the agency sends the same caregiver sometimes. Only 2% of paid home care recipients who hired a caregiver from an agency reported that the agency never sends the same caregiver. From a continuity of care perspective, this finding is positive.

TABLE 5: The Relationship between Service Quality Measures, Socio-Demographics and Disability Status
  The Staff Provides Quality Care The Staff is Reliable The Staff Spends Enough Time With Me
Disability Status
   Less than 2 ADLs 91% 93% 84%
   2-4 ADLs 89% 89% 82%
   5+ ADLs 81% 87% 78%
   Dementia 89% 92% 80%
   Less than 65 71% 84% 85%
   65-74 85% 87% 82%
   75-79 89% 89% 81%
   80-84 85% 88% 81%
   85+ 92% 93% 80%
Marital Status
   Married 89% 91% 85%
   Unmarried 86% 88% 79%
   Female 86% 89% 80%
   Male 89% 90% 83%
Parental Status
   Have children 87% 89% 80%
   No children 87% 88% 88%

Home care recipients were less likely to indicate their care needs were being met, but more likely to indicate they were satisfied with their current caregivers and with other aspects of their care experience. Conversely, nursing home residents are most likely to indicate that their care needs are being met and least likely to indicate that they were very satisfied overall and with specific measures of care quality. These results taken together seem to indicate that whether or not a person feels their needs are being met by their current provider may have little to do with how satisfied they are with that provider and perhaps more to do with whether or not they are satisfied with their overall choice of where to receive care.

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