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


In this report, we explored a snapshot of LTC insurance policyholders at the time that they were making a decision where to use paid care. Not surprisingly, half of paid service users chose to use their policies to pay for care at home, but about one-third is using ALFs. Even in the face of coverage for all three services modalities, 19% are still choosing to go in to a nursing home for their care.

The highest percentage of those under age 75 is living at home, while those choosing assisted living are the oldest, although not the most disabled. ALF residents are more likely to be single (not married) and female, suggesting that these individuals may be doing so to meet both social and safety needs; and may be moving at a time when they are still able to so that they can “age in place” if they begin to require more assistance or become more disabled.

A goal of this study was to interview people as close to the beginning of their use of paid care as possible. The majority had begun paid care use within the last three months, with paid home care recipients receiving their care for the shortest amount of time. This length of time is ideal as it is close enough to the decision-making process to allow accurate recall, yet long enough for individual’s to have developed opinions about their choices and caregivers.

We also asked about current unpaid care use. We were particularly interested to see if those residing in nursing homes were still receiving unpaid help with their daily activities, even though they were in a nursing home. It turns out that 35% of them report that they are currently receiving unpaid help from family and/or friends while living in a nursing home. It is common to assume that those in nursing homes receive all the care they need from the staff there; however, it appears that a significant proportion of them are getting help with their daily activities from family. This could suggest a shortage of staffing in the nursing homes, or it could just be that while family is there visiting they lend a hand and assist their loved ones.

There are a number of decisions that must be made when an individual becomes disabled. When do I decide I can no longer manage on my own and need to pay someone to assist me? Where do I want to live while I am getting paid care? How do I choose a specific provider for my care? We examined all three of these areas in this baseline report and found that needing more help and having assistance when it is needed are important motivators for people regardless of service setting choice, disability status and demographics when making these decisions.

The majority of people living at home and in assisted living decided to begin using paid care because they need more help and could no longer manage on their own. Those who are living in nursing homes were much more varied in their reasons; with the majority saying it was either that they needed more help or had an acute incident. Interestingly, those in assisted living were much more likely to say that safety concerns was a common motivator for paid care use than those in all other service settings. This is likely due to their advanced age and the fact that less are married.

Across all service settings and regardless of demographics (i.e., marital status, gender, age) and disability status, having someone available to assist when needed was ranked as the most important consideration when deciding where to receive care, with more nursing home residents saying this than those in other settings. This was followed by the desire to feel safe in a particular choice of setting.

Not surprisingly, the majority of home care residents (93%) said that staying at home was there first choice, while smaller proportions of nursing home residents (65%) and ALF residents (75%) said that their current location was their first choice. While the majority of those not living at home said they considered it, they did not actively pursue staying at home as is evidenced by the fact that few actually visited alternative care settings or put themselves on a waiting list for a different type of care.

It turns out that ALF residents are the ones who seem to have done the most “research” when choosing the specific facility. They were most likely to have visited other ALFs, compare costs among ALFs and obtain quality information. While cost did not have a great influence on an individual’s choice of specific provider, reputation, location and recommendation were all ranked high among those receiving paid care.

We also gathered information about how satisfied individuals were with their choice of provider. While there were high levels of satisfaction across all service settings across multiple characteristics, it was striking that a higher percentage of home care recipients compared to residents in nursing homes or ALFs reported that their needs were not being met or that they needed more help than they were currently getting. It would seem that whether or not a person is satisfied with their specific provider may have little to do with their belief that their needs are being met.

Only a small proportion reported using care management services at the outset of paid care use and most of those surveyed said that they would be receiving the same amount of care in the same place if they did not have their LTC insurance policy. It will be important to see if these measures change over time. It could be that the potential value of having a LTC insurance policy (or using a care manager) is not realized until a person is receiving services for a longer period of time.

While this report focuses solely on the results of the baseline interview of claimants at the beginning of their paid service use, it provides a detailed and insightful look at the decision-making process and choices made by disabled elders and their families. Understanding how these choices, satisfaction levels, use of services and transitions change over time will be explored further at the conclusion of the telephone follow-up interviews.

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