Rhythmic rush: everyday outpatient care within microgeographies of home and “service complex systems”

The factors influence demand and supply of long term care were explored by numerous previous research. Demand and supply, however, are both economic terms. There is a need to incorporate the economic activity such as demand and supply within the general framework of health and social care. This is because it is a challenge to use them in the health and social care in which their characteristics are far from those in a free market. Firstly, the demand and supply used on issues of health and social care and their limits to achieve the social objectives are explored. Then, the case of long term care in Taiwan is discussed by describing the characteristics of long term care market in Taiwan and the forms that government policy may take in its efforts to realize social objectives more fully. As noted, the factors that influence demand and supply of long term care are dynamically intricate. Any interpretation should be used with caution in considering of how and why the demand and supply having been used on issues of long term care and their limits.

The long-term care (LTC) market can be differentiated on the basis of the locations at which seniors in need for health and personal care receive these services. The at-home care market appears to be the fastest growing in popularity. It largely consists of highly-specialized niche markets of professionals or organizations providing narrow lines of services. In recent years, these organizations have been creating alliances to achieve synergistic effects of efficiency, better serving the patients’ preference for receiving healthcare and personal care from one source. The trend towards integration of healthcare with personal care services for similar reasons is also evident in adult day care facilities. In contrast, nursing homes have been scrambling to find ways to survive, and many are forced to go out of business or find niche markets with special needs. As a result of greater understanding of Alzheimer’s disease and related disorders (ADRD) sufferers and their care requirements, special care units have been developed to provide optimum care for the increasing numbers of people with this progressively debilitating disease and to offer some relief from the burden of caring for victims of Alzheimer’s disease. The LTC market will continue to experience opportunities for diversification with home health care, adult day care and sub-acute facilities offering viable alternatives to consumers.

This paper analyzes how markets for old-age care respond to the aging of populations. We consider how the biological forces, which govern the stocks of frail and healthy persons in a population, interacct with economic forces, which govern the demand and suppoly for labor-intensive care. Many economists have argued that aging will raise the market demand for long-term care, and hence price and quantity through classic market effects. We argue that the direct effect of aging is to lower the demand for market care by incresing the supply of home production. By influencing the length of frail lifetimes, aging may also have a further indirect demand effect, which may reinforce or counteract the direct negative demand effect. By providing healthy spouses, the marriage market provides care-givers for home production of long-term care; therefore, growth in old-age longevity may lower the demand for market production. Growth of elderly males serves to contract the long-term care market becuase it eases the scarcity of men in the old-age marriage market; growth of females serves to expand market care because it worsens the scarcity of men. These predictions lend themselves to an interpretation of the rapid deceleration in output growth that has taken place in the US over the last two decades, despite a constant rate of longevity growth and enormous growth in demand subsidies: since growth in elderly males has risen dramatically relative to growth in elderly females, the rate of long-term care growth has slowed significantly. We test our predictions empirically using state- and county-level evidence on the US market for long-term care in nursing homes over the last three decades. The evidence provides support for our predictions concerning the response in output growth to aging and the contraction of output due to the aging of males.

A major problem facing many U.S. retirees is accessing and paying for long term care. The 2019 National Association of Insurance Commissioners (NAIC) guide on long-term care insurance estimates that, of the individuals living in the United States who reach age 65, about 70% are expected to need some form of long-term care at least once in their lifetime and about 35% are expected to enter a nursing home at least once in their lifetime. Although Medicare covers most of a U.S. retiree’s medical care, Medicare does not ordinarily pay for long-term care. U.S. retirees often can access long-term care services via the Medicaid program, which is a means-tested program geared to lower income Americans. But, to quickly qualify for Medicaid, many retirees take drastic steps, such as transferring their assets to family members. When access to long-term care is not urgent and long-term planning is an option, most U.S. states have developed so-called Partnership for Long-Term Care (PLTC) Program insurance policies that provide access to Medicaid services while sheltering some or all of a retiree’s assets. In this article, we propose a hybrid annuity product called a doubly enhanced Medicaid partnership annuity (DEMPAN) that combines an annuity with a long-term care rider that is integrated within the framework of a qualified partnership policy. (Outside the United States, bundled retirement products similar to DEMPANs are often called life-care annuities.) To analyze our DEMPANs, we use a multistate model of long-term care with health states that are based on a retiree’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and cognitive ability. A significant contribution of this article is to explicitly model how the quality of long-term care a retiree receives affects the retiree’s health state transition probabilities used in the multistate model. As higher quality of care usually comes at a higher cost but with better health outcomes, we provide an example that explores an expected discounted utility maximizing retiree’s optimal choice of DEMPAN. Our example showed that it may be optimal for retirees who purchase DEMPANs to simply buy average quality long-term care. We hope DEMPANs fill a gap in the long-term care market by providing an important tool for elder care planning for those in the Medicaid penumbra (i.e., in the middle- and lower-middle-income classes). Retirees who purchase DEMPANs have the benefits of an annuity, private long-term care, Medicaid assistance with paying their long-term care bills, and some degree of asset protection from Medicaid estate recovery.

Studies show risks in the psychopharmacological care of older people with long-term care needs. In developing recommendations on the handling of psychotropic drugs in outpatient long-term care, the perspective of care professionals has so far received only sporadic attention. The study aims to explore perspectives in outpatient care on the use of psychopharmaceuticals in the care of older people in need of long-term care. The importance of the topic, problems in dealing with it, priorities of measures as well as knowledge and distribution of instruments are examined. An online survey was used to interview personnel in leading positions in arandom sample of 20% (n = 2957) of the 15,138 outpatient long-term care facilities licensed with acare contract in 2019. Statistical data analysis and content analysis of answers to open questions was conducted. A total of 212 questionnaires was completed (7.2% response rate), 87.2% of the respondents evaluated the importance of dealing with psychotropic drugs as high and 46.2% were confronted with problems related to psychotropic drugs in their own work. Participants located problems predominantly with physicians (53.1%), but also with patients (19.6%), nursing staff (11.2%) and caring relatives (6.1%). The use of measures varied. Cooperation with physicians and-with less priority, but still important-the qualification of nursing staff and the involvement of caring relatives were named as central fields of action. The heterogeneity of experiences and initial conditions regarding the handling of psychotropic drugs in outpatient long-term care should be taken into account when developing corresponding recommendations for action and implementation concepts.

In this paper, we suggest a view of young people's digital technology use as negotiated social and literate practice. Rather than emphasising the boundedness of school and home spaces and literacy practices, we argue that young people's practices that develop around their use of digital technologies flow across these spaces, making simple distinctions and binaries about use in each domain problematic. To help illustrate, we present ethnographic case study snapshots of 15–16-year-olds from contrasting schools in and around Melbourne, Australia. In our thinking, we bring together insights from a range of work in the hope of prompting a reframing and rethinking of the relationship between home and school and the other spaces young people inhabit and create. We use Bakhtin's ideas about ‘dialogic negotiation’ and Bourdieu's notion of habitus to suggest that texts, meanings and practices do not emerge wholly from one social/physical domain but are traced and sourced from the whole life world of experience. In this framing, young people's engagement with language, learning and technology might be characterised as a dialogic negotiation of a complex range of texts and practices that flow across and between school, home and other spaces.

The collaborative project Zukunft:Pflege seeks to promote long-term employability through the development of skills and competences, enhancing motivation and preserving the health of outpatient care workers. To this end, work process-related and organizational learning strategies for small- and medium-sized enterprises were drawn up and systematically linked together and enhanced by developing and mobilizing resources at a network level. This chapter deals with the coordination aspect of the Zukunft:Pflege network. This network comprises outpatient nursing, long-term care services, and so-called value partners such as continuing education providers and outpatient care associations in the Bremen region. In general, inter-organizational networks tend to waver between cooperation and competition. The primary objective of cooperation can be attained provided the coordinators succeed in promoting the development of human and relational potentials and ensuring relationships of trust. To this end, the network agency places emphasis on interactive learning processes among the network partners. Building on experiences from such cooperation, knowledge transfer via the network can be encouraged, potentials and expectations promoted, and the basis for cooperation further strengthened. The main functional focus of the network agency lies in coordination of the various interests of the network members, identification of synergy potentials and thence development of possible courses of action for promoting long-term employability in outpatient nursing and long-term care work.

This paper analyzes how markets for old-age care respond to the aging of populations. We consider how the biological forces, which govern the stocks of frail and healthy persons in a population, interact with economic forces, which govern the demand for and supply of care. We argue that aging many times may lower the demand for market care by increasing the supply of family-provided care, which substitutes for market care. By providing healthy spouses, aging may increase the supply of family care-givers. Unexpectedly, this implies that relative growth in healthy elderly males may contract the long-term care market, while relative growth in healthy elderly females may expand that market. We examine these implications empirically using individual, county, and national-level evidence on the US market for long-term care and find substantial support for them, particularly the negative output effect of growth in elderly males. We then decompose the per capita growth in long-term care output over the last three decades into the component accounted for by improvements in health and that accounted for by relative growth among elderly males. The novel effects of unbalanced gender growth among the elderly appear important in explaining the net decline in US per-capita output over the last 30 years, a decline which seems remarkable given the simultaneous rise in demand subsidies for long-term care, declining fertility rates, rising female labor-force participation, and the deregulation of entry barriers to the nursing home industry.

The long-term care industry first developed in response to the need for efficiency and economy of scale for those needing health care beyond the acute care setting and those providing the care. Long-term care facilities began as poor houses and religious care homes in response to the need for care of the elderly and infirm. Following the addition of Medicare and Medicaid as payer sources, the long-term care industry exploded. Anyone could start a nursing home if they had the money and the building to house the patients. Nursing homes were first developed to replicate the acute care setting and were often attached to the acute care setting with physicians as the administrators. As for-profit entities entered the long-term care arena, the nursing home became freestanding and without the medical connection to a specific hospital or physician group. The development of assisted living facilities provided another avenue to break into the long-term care market and make an even greater profit than was realized in the nursing home setting. With the majority of assisted living facilities only private-pay, the profit margins grew, creating an environment of growth and expansion.

Meso-level Comparison of Mental Health Service Availability and Use in Chile and Spain

Staff turnover in the long-term care (LTC) sector in England is perceived to be relatively high. Most job leavers do not leave the sector, but rather move to other LTC employers. Nevertheless, there are concerns that the high ‘churn’ has a negative impact on continuity and quality of care, care providers’ recruitment and training costs, and the remaining staff workload and motivation. This study aimed to provide missing quantitative evidence on the drivers of LTC staff retention in England, with a focus on job quality. We used yearly data (2016 to 2019) from a large, employer-employee dataset covering about half of England’s LTC market: the Adult Social Care Workforce Dataset. After controlling for observed individual, organisational, and local market characteristics as well as unobserved worker and employer heterogeneity, we found that, everything else being equal, wages and employment conditions (i.e. full time contracts and contracts with guaranteed working hours) significantly reduce job separation. For example, a 10 per cent wage increase from the sample mean would have reduced the job separation rate by about 3 ppt. Our results also show that the wage effect was substantially downward biased (i.e. closer to zero) when not accounting for unobserved effects: the estimated reduction in job separation rate of a 10 per cent wage increase was only 1 to 1.5 ppt. Our findings show that improving pay and employment conditions for LTC staff can improve staff retention in LTC and stress the importance of accounting for unobserved variable bias.

Nursing Home Reform in the Context of National Long-Term Care Services and Policy: The Devil in the Details of the National Academies Report.

Since the market for long-term care (LTC) services is expected to grow rapidly in the years ahead, the case for hospital diversification into LTC is a strong one. This article discusses the major LTC diversification options, the cost of entry, potential profitability, potential problems, and recommendations for implementing them.

The market for long-term care (LTC) insurance is much smaller than economic theory predicts. One reason is that premium markups are prohibitively high. We aim at quantifying markups for LTC insurance due to mortality and morbidity risk. To this end, we model a shareholder value maximising insurance company that is subject to solvency regulation. Because liabilities from LTC insurance (which depend on future morbidity and mortality) are more volatile than liabilities from annuities (which only depend on future mortality), capital provisions to ensure compliance with regulatory solvency requirements are higher if an insurance company offers LTC insurance instead of annuities. At the same time, a higher volatility in the LTC insurance segment also implies a higher expected payoff to the insurance company’s shareholders. To quantify which effect prevails and which product policy is optimal, we conduct an empirically calibrated simulation study with stochastic mortality and LTC needs. Our results show that offering LTC insurance increases the upside potential to shareholders, but that effect is more than offset by a higher need for external capital. Consequently, if shareholders are to accept an LTC insurance segment, holders of an LTC insurance policy need to pay considerable markups. The more LTC insurance contracts the insurer has sold, the higher the markups.

This chapter reviews the empirical literature on nursing home utilization. It also reviews the fundamental role played by Medicaid. The chapter suggests that incremental changes that may occur in Medicaid and identifies an interdisciplinary research agenda. It focuses on the role of Medicaid, the nature of the private segment of the market, and the emergence of private long-term care insurance. The private nursing home market is also characterized by the presence of long-term care insurance. Tax incentives for the purchase of private insurance or for expenditures on long-term care services could be put in place. Fundamentally, policy analysis of long-term care markets must take a much stronger market perspective. Despite the increasing sophistication that has come to studies of the risk of nursing home placement and estimating nursing home length of stay, these are fundamentally episode-based approaches. The forgoing growth projections imply potentially large changes in the nursing home market.