Service Use and Transitions: Decisions, Choices and Care Management among an Admissions Cohort of Privately Insured Disabled Elders. A. Socio-Demographic Characteristics


Table 2 highlights the socio-demographic characteristics of the admissions cohort by service setting. Each service setting is labeled with a different letter. For example, individuals receiving paid home care are in column (A), whereas those who are living at home but have not yet begun receiving services are labeled as column (D). These letters are assigned so that we can analyze the extent to which there are statistical differences between findings across service settings. If a finding has the letters (BC) by it, this suggests that it is statistically greater/higher than the findings in columns B and C. If a finding has a letter (D) by it, this means that it is statistically greater/higher, than the finding in column D. We report differences that are significant at the 0.05 level.

TABLE 2: Socio-Demographic Characteristics of Admission Cohort by Service Setting
Socio-Demographic Characteristics Receiving Paid Care at Home
Nursing Home
Assisted Living
Not Yet Receiving Paid Care
   Average Age 77 80 AD 82 ABD 78
   Below 65 8% BC 2% 1% 9% BC
   65-74 21% C 15% 10% 21% C
   75-79 27% C 28% 19% 22%
   80-84 27% 28% 35% D 25%
   85 or above 18% 27% 35% AD 24%
   Male 32% 41% C 26% 35% C
   Female 68% 59% 74% BD 65%
Marital Status
   Married 49% BC 36% C 24% 47% C
   Widowed 40% 54% AD 65% AD 41%
   Single 2% 4% 5% 4%
   Separated 2% 1% 2% 2%
   Divorced 6% 6% 4% 7%
   Partner 1% --- --- ---
Spouse’s Employment Status
   Yes -- full-time 4% 1% 1% 9%
   Yes -- part-time 7% 8% 3% 7%
   No 89% 91% 97% D 84%
Living Arrangement
   Alone 41% --- --- 40%
   Spouse 45% BC 1% 4% 42% BC
   Daughter/Son 9% BC 1% 1% 11% BC
   Facility --- 98% D 95% D 1%
   Other 5% C --- 1% 5% C
   Spouse and child 1% --- --- 2%
Education Level        
   Less than high school 3% 6% 6% 4%
   Some high school 4% 3% 6% 5%
   High school graduate 19% 28% A 34% A 31% A
   Technical/trade/vocational school 7% 12% D 10% 6%
   Some college 22% 14% 15% 18%
   College graduate 26% 23% 22% 21%
   Graduate degree 20% C 13% 8% 16% C
Presence of Children
   Yes 91% BC 83% 85% 89%
   No 9% 17% A 15% A 11%
Any Children Living within 25 Miles
   Yes 68% 73% 82% AD 68%
   No 32% C 27% 18% 32% C
   Less than $50,000 63% 82% A 86% AD 75% A
   $50,000 or more 37% BCD 19% 14% 25% C
   Less than $25,000 34% 41% 50% AD 30%
   $25,000 - $34,999 17% 19% 22% 24%
   $35,000 - $49,999 14% 22% 14% 19%
   $50,000 - $74,999 20% BC 9% 9% 20% BC
   $75,000 - $99,999 8% C 4% 2% 4%
   $100,000 - $149,999 4% 4% 1% 2%
   $150,000 or above 2% 1% 2% 1%
   Yes 88% BC 71% 62% 86% BC
   No 12% 30% AD 38% AD 14%
Home Modification within the Last Year
   Yes 38%   32%
   No 62% 68%
Housing Assets        
   Less than $50,000 2% 1% AD 5% 2%
   $50,000 - $99,999 18% 25% 26% D 16%
   $100,000 - $199,999 33% 46% 45% A 35%
   $200,000 - $299,999 14% B 4% 14% B 19% B
   $300,000 - $399,999 8% 8% 5% 14% AC
   $400,000 - $499,999 11% C 5% 1% 7% C
   $500,000 - $799,999 7% 2% 3% 5%
   $800,000 and above 8% D --- --- 2%

Age, Gender and Marital Status

With respect to age, the results show that individuals newly admitted to ALFs are older than individuals entering all other settings. Over one-third of new entrants to ALFs are over age 85. This service modality typically serves a less disabled population than what is found in nursing homes (Spillman, et al. 2002). Thus, it may be the case that many of the new private LTC insurance claimants who choose to enter ALFs are making a life-changing move while they are physically able to do so and are preparing for the time when they gradually become more disabled and may require more intensive care. Also, many ALFs now have specialized Dementia Care Units, so that individuals who may be showing early stages of cognitive decline prefer to age in place at an ALF rather than having to move to a nursing home at later stages of dementia. New entrants to nursing homes tend to be older than individuals in home care.

In terms of gender, one statistic stands out: overwhelmingly the claimants entering the formal service system are female, even in the home care setting. Males are less likely to make claims on their policies; while a higher percentage of females have policies -- roughly 55% compared to 45%. However, most of the gender difference in type of service use cannot be explained by policy ownership. Differential mortality and morbidity rates, as well as the availability of family supports likely account for most of the difference in formal service use. Compared to other service settings, the admission cohort entering the nursing home tends to have the highest percentage of males. On the other hand, women represent the highest percentage of new entrants to ALFs. These facilities provide a highly social, as well as protected, environment to individuals capable of independent living.

Regarding marital status, claimants living at home are more likely to be married than are those entering residential care settings. This is not surprising, given that married individuals are able to provide care to each other and the formal service system typically supplements a level of care already being provided by family members. Those newly admitted to ALFs are least likely to be married and in fact, less likely to be married than those in nursing homes. Two-thirds of ALF claimants report being widowed. This further supports the notion that many individuals entering ALFs are doing so to meet both social and “protection” needs; given their advanced age, they may be frail, but as we shall see in the findings that follow, they tend to be the least disabled of the claimant population.

Those who have living children are more likely to enter the service system through the home care setting. Somewhat surprisingly, however, among those who have children living within 25 miles, the highest percentage is entering ALFs. This service modality provides a more protected environment than the home and therefore may be an attractive way for frail independent elders to age in place and access services from the facility, as they need them. Concerns about safety, falls, and social isolation are addressed in ALFs, and nursing homes are still viewed as serving a population that is already highly dependent.

Education and Wealth Status

In general, individuals who purchase LTC insurance tend to have higher levels of education and are wealthier than elders in the general population. Individuals receiving care at home tend to be more highly educated than those receiving care in alternative settings. In fact, 46% of home care recipients have at least a college degree compared to 36% of those entering nursing homes and 30% of those entering ALFs. Higher income, homeownership, and greater home values are all positively associated with individuals receiving paid care at home. Note that 13% of nursing home residents and 34% of ALF residents are in the process of or have already sold their homes (not shown in Table 1). Whereas half of claimants newly entering assisted living have incomes less than $25,000, for those in home care, the figure is closer to one-third. (Given the relatively high cost associated with ALFs, it is surprising that such a high percentage has incomes less than $25,000; on the other hand, it may be that insurance or proceeds from the sale of their homes are financing the bulk of the costs of care for these individuals.)

The findings regarding income status are particularly interesting. Among people purchasing policies in the early to late 1990s -- the individuals who would likely comprise the bulk of claimants in this sample -- roughly 60% had incomes less than $35,000 (HIAA 2000). This is roughly comparable to the income distribution of claimants in this sample. It should be noted that the “lower income” claimants in this sample (those with incomes less than $35,000) would be considered to be in a middle income bracket in a non-insured environment. It would appear that having LTC insurance reduces or even eliminates the effect of income variation on the demand for paid care. This has been documented in previous studies of LTC insurance claimants as well (Cohen, et al. 1999). In this sample, as in previous research, the effect of income on the use of paid services is overwhelmed by the presence of private LTC insurance.

An unexpected finding is the proportion of individuals living in their homes who have made some modification to their home environment within the past 12 months. Almost two in five individuals receiving care at home have made some type of home modification (see Figure 4). Most of those who are living at home have installed grab bars. This may suggest that these claimants have been experiencing a gradual increase in disability prior to deciding to file a claim under their LTC insurance policy. It may be that those who make some modification to their home are planning ahead and have an intention to try to remain in their own homes despite disability.

FIGURE 4: Home Modification Among those Living at Home

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