Community-based Long-term Care Services Research Articles

Services in public long-term care insurance in Japan.

In Japan, a public long-term care insurance system was launched in 2000. Residents can receive long-term care according to their care needs, as determined by a nationally standardized certification system. The present report describes the details of the long-term care services covered by public insurance. The Long-Term Care Insurance Act categorizes services into three major types: in-home, nursing-home, and community-based long-term care services. In-home care services include visiting, commuting, short-stay, and other services. Welfare, health, and medical facilities provide nursing-home care services for the elderly. Community-based care services were categorized into visiting, commuting, nursing-home, and composite services.

A POLICY COMPARISON OF THE EVOLUTION OF COMMUNITY-BASED LONG-TERM CARE POLICY BETWEEN TAIWAN AND THE UNITED STATES

Abstract Governments globally have been facing pressure to develop and implement effective policies to support population aging. This approach was historically rooted in a perception that as we age we become increasingly incapacitated. This research seeks to understand how policies in two countries valuing unpaid care differently, developed and implemented Long-term services and supports (LTSS). We compare the federal level efforts of implementing LTSS within the United States (U.S.) and Taiwan. Relying on a pre-established comparative framework developed by Richard Rose, we utilized a deductive analytical approach to assess the differences in policy options and timelines across Taiwan and the U.S.. After attending this session, participants will develop a deeper understanding of how Taiwan and the U.S. are working to offer home and community-based long-term care services. It wasn’t until the 1980s for the U.S. and late 1990s for Taiwan that LTSS were introduced with the intention of supporting people to live as independently as possible in their own homes for as long as possible (e.g., Department of Health and Human Services, 3-year Care Service Development Plan). It is likely that the delay in LTSS delivery between the two countries is rooted in the role that unpaid support is expected to play. There is increasing evidence that countries are shifting their policy efforts to focus less on aging as a social dependency and more on policies that encourage healthy longevity.

Factors associated with perceived caregivers' willingness to provide care among older adults with disabilities in China.

The aim of this study was to analyze the status quo and associated factors of care recipients' perceptions of caregivers' willingness to provide care among disabled older adults in China. Thus, this study contributes to our understanding of vulnerable older populations who are at a high risk of receiving support from informal caregivers who are unable or unwilling to take the caregiver role. We analyzed the cross-sectional data of 3,539 disabled older adults who received informal care at home from the seventh wave of the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). Multiple logistic regression models were used to examine the variables associated with the respondents' perceived caregivers' willingness to care from five aspects: respondents' sociodemographic attributes, health-related data, family endowment, access to health care services and community-based long-term care services (CBLTCS). This study found that the majority of disabled older adults (90.9%) had a positive attitude toward their caregivers' willingness to care and the care they received; however, 7.0% of the adults were concerned about their caregivers' ability to handle the care. Moreover, there was a small number of disabled older people (2.1%) who felt that their caregivers were reluctant to care or lacked patience. The results from the multiple logistic regression showed that disabled older adults with socioeconomic disadvantages (living in rural areas, being poor and with no children who frequently visited) or high demand (with severe disabilities or cognitive impairment) were more likely to consider that their caregivers needed respite care. Those adults with anxiety symptoms, a lower amount of care time, poor self-rated financial status and poor accessibility to health care services were more likely to report that their caregivers were reluctant to administer care. This study found that living in rural areas, being poor, with no children who frequently visited, severe disabilities or CI were positively associated the care recipients' perception that caregivers needed respite care. While anxiety symptoms, a lower amount of care time, poor self-rated financial status and poor accessibility to health care services were significantly associated with care recipients' perception of caregivers' reluctance to care. Our findings highlight the awareness of monitoring informal carers' willingness to care or capability to enact caring tasks.

Approaching person-centered long-term care: The trajectories of intrinsic capacity and functional decline in Taiwan.

To examine the longitudinal trajectory of intrinsic capacity over a 3-year period among long-term care recipients in Taiwan, its association with functional decline and the onset of severe dependency. A total of 9448 individuals aged ≥50 years utilizing home and community-based long-term care services with complete data from three separate evaluations in Taiwan were included in the study. We carried out a latent class linear mixed model to identify heterogeneous patterns of intrinsic capacity over time, a mixed-effects model to investigate their impact on activities of daily living and a Kaplan-Meier analysis to examine the onset year of severe dependency among different intrinsic capacity classes. The results identified four classes sharing similar longitudinal the intrinsic capacity trajectories: "high-stable" (20.13%), "normal-stable" (40.58%), "sensory-dysfunction" (29.53%) and "all-dysfunction" (9.76%). Individuals with predisposing characteristics were associated with lower activities of daily living, with the exception of age and education level. In addition, the poor intrinsic capacity class (b from -16.94 to -6.61, P < 0.001) had a worse evolution in terms of activity of daily living scores, and was associated with an earlier onset of severe dependency in 2.5 years in the all-dysfunction class. Heterogeneous patterns of intrinsic capacity that delay further functional decline are promising markers of function trajectories for a person-centered care approach in long-term care services. Targeting the needs of intrinsic capacity groups to prevent functional decline offer insights into: (i) strengthening function-centered care modalities to delay severe dependency as individuals get older; and (ii) validating regular monitoring intrinsic capacity as an early warning system to achieve healthy aging. Geriatr Gerontol Int 2022; 22: 516-522.

Fewer potentially avoidable health care events in rural veterans with self-directed care versus other personal care services.

Rural residents face more barriers to healthcare access, including challenges in receiving home- and community-based long-term services, compared to urban residents. Self-directed services provide flexibility and choice in care options and may be particularly well suited to help older adults with multiple chronic conditions and functional limitations who reside in rural areas remain independent and live in the community. We conducted a retrospective observational study to understand whether differences in health outcomes between Veteran-Directed Care (VDC), a self-directed Veterans Health Administration (VHA)-paid care program, and other VHA-paid home- and community-based personal care services vary in rural/urban location. The sample included 37,395 veterans receiving VHA-paid home- and community-based long-term care services in FY17. Our primary outcomes were changes in monthly incidence of VHA or VHA-paid community acute care admissions, nursing home admissions, and emergency department (ED) visits. We used fixed effects logistic regression models on unmatched and coarsened exact matched cohorts, stratified by rural/urban location. Both urban and rural VDC recipients were significantly less likely to be admitted to VHA-paid nursing homes, compared to those receiving other VHA-paid personal care services (rural: incremental effect=-0.22, [-0.30, -0.14]; urban: incremental effect=-0.14, [-0.20, -0.07]). Rural, but not urban, VDC enrollees had significantly fewer VHA-paid acute care admissions and ED visits, relative to recipients of other VHA-paid personal care services (acute care, rural: incremental effect=-0.07, 95% CI=[-0.14, -0.01], urban: incremental effect=-0.01, [-0.06, 0.03]; ED, rural: incremental effect=-0.08, [-0.14, -0.02], urban: incremental effect=0.01, [-0.03, 0.05]). VDC recipients had fewer incidents of potentially avoidable VHA-paid health care use, compared to similar veterans receiving other VHA-paid personal care services. These differences were more pronounced among rural VDC recipients than urban VDC recipients.

Behavioral Health, Social Engagement, and Long-Term Care Services Use Among Community Older Adults: USA vs. Taiwan

As healthcare advances, older adults are living longer. While 90% of older adults prefer aging in their own homes and communities, it is important to examine key factors influencing healthy aging-in-community and community-based long-term care (LTC) services available in different countries. This symposium examines behavioral health, social engagement, and LTC services utilization among community-dwelling older adults in the USA and Taiwan. Lessons learned from older adults across countries will provide insights for tailored community-based LTC services and program development. Dr. Hou from The University of Central Florida (UCF) will highlight similarities and differences in behavioral health profiles and the topics that most interest community-dwelling older Americans participating in three aging-in-community programs in Central Florida. Dr. Wang from Case Western Reserve University will examine the impact of neighborhood social cohesion on mobility among community-dwelling older Americans aged 65 and older from the national Health and Retirement Study. Dr. Liu from National Cheng-Kung University in Taiwan will share results of healthy lifestyle on quality of life among community-dwelling older adults in southern Taiwan. Dr. Young from State University of New York at Albany will compare long-term care use among community-dwelling older adults with and without dementia in Central Taiwan. Finally, Drs. Cao and Hou from UCF will analyze home and community-based services in the USA versus Taiwan. This symposium will further discuss similarities and differences of key factors related to healthy aging-in-community, along with practical recommendations and lessons learned across countries and cultural environments to improve community-based long-term care services and programs.

Perceived unmet needs for community-based long-term care services among urban older adults: A cross sectional study

The purpose of this study was to explore the perceived unmet needs for community-based long-term care services among older urban adults in China. We analyzed the cross-sectional data of 5,201 urban community respondents ≥65 years of age from the seventh wave of the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). The chi-squared automatic interaction detection technique was used to examine the variables associated with older adults’ unmet needs for four common types of community-based services: personal care, grocery shopping, home visits, and psychological consulting. We found that the majority of the older adults perceived that they needed the four services, but only 9%–27.4% of the respondents reported that their perceived needs were met. There was a high prevalence of unmet community-based service needs (51.3%–55.5%) among urban older adults in China. Factors associated with unmet needs included depression status, ADL (activities of daily living) limitations, self-rated health, number of surviving children, educational attainment, and marital status. The results suggest that policy makers should develop services targeting specific segments of the older population, increasing the adequacy of services provided.

Stakeholder and Data-Driven Fall Screen in a Program of All-Inclusive Care for the Elderly: Quality Improvement Initiative.

The Program of All-Inclusive Care for the Elderly (PACE) delivers community-based long-term care services to low-income, nursing home eligible adults. In the PACE population, one of the most common reasons for hospitalizations is falls. The purpose of this quality improvement study was to create a stakeholder-driven process for developing a fall risk screen and evaluate how well this process discriminated injurious and noninjurious fallers. The quality improvement design was a prospective, longitudinal data collection for 5 PACE programs in Colorado. Physical therapists collected the Short Physical Performance Battery (SPPB) on participants at least annually. The Kotter practice change framework guided the processes for practice and organizational change in developing and implementing a fall screen. An iterative, stakeholder, and data-driven process allowed our team of researchers and a PACE program to establish a fall risk screen to stratify PACE participants. We provided feedback to PACE staff regarding screening rates and results on discrimination of faller status to promote continued uptake of screening and discussion regarding next steps. Rehabilitation therapists screened 66% of the PACE population, and participants were stratified into high risk (1-7 points) or low risk (8-12 points) based on the SPPB. Participants with low SPPB scores had 79% greater risk of a fall (risk ratio [RR] = 1.8; 95% confidence interval [CI], 1.5-2.1) and 86% greater risk of an injurious fall (RR = 1.9; 95% CI, 1.4-2.4), compared with those with high SPPB scores. Our study describes a collaboration to address fall rates in a PACE population. Program of All-Inclusive Care for the Elderly clinicians can use the identified cut-offs to stratify PACE populations at risk for falls and allocate scarce rehabilitation resources efficiently to best serve participants at highest risk, while using less resource-intensive interventions for those at lower risk.

EFFECTIVENESS OF HOME- AND COMMUNITY-BASED SERVICES IN DECREASING HEALTH CARE EXPENDITURE IN TAIWAN

Ideally, continuum of care involves wide-ranging health and long-term care (LTC) services. Taiwan’s National Health Insurance scheme and 10-Year Long-term Care Plan attempts to provide universal and fundamental services of continuum care. However, the accessibility of these services for care recipients remains unclear. This study aims to examine the effectiveness of continuum care in decreasing the healthcare expenditure of LTC recipients using home- and community-based services (HCBS). Data collated from the 2010–2013 Long-Term Care Service Management System (N = 77,251) were subjected to latent class analysis to identify subgroups of recipients using HCBS. Subsequently, the 1-year primary care expenditure after receiving HCBS was compared through generalized linear modeling. Three discrete HCBS subgroups were found: home-based personal care (HP), home-based health care (HH), and community-based care (CC). No difference in the number of visits to doctors and the average primary care expenses was observed between the HP and HH subgroups. However, considering physical and psychosocial confounders, care recipients in the CC subgroup recorded a higher number of visits to doctors (β = 3.05, SD = 0.25, p < 0.05) and lower primary care expenditure (β = -98.15, SD = 43.17, p = 0.02) than the other two subgroups. These findings suggest that LTC recipients in Taiwan may obtain better continuum care only for CC service recipients. Additionally, community-based LTC services may lower the cost of health expenditure after 1 year.

Homebound Status and the Critical Role of Caregiving Support

ABSTRACT The homebound population relies on both paid and family caregivers to meet their complex care needs. In order to examine the association between intensity of caregiving support and leaving the home, we identified a population of community-dwelling, homebound Medicare beneficiaries age ≥65 (n = 1,852) enrolled in the 2015 National Health and Aging Trends Study and measured the support they received from paid and family caregivers. Those who had ≥20 h of caregiving support per week had 50% less odds of being “exclusively homebound” (rarely or never leave home) (OR 0.56, p < .01). Policies that facilitate increased support for family caregivers and better access to paid caregivers may allow homebound individuals who would otherwise be isolated at home to utilize existing community-based long-term care services and supports.

Are community health workers more effective in identifying persons in need of home and community-based long-term services than standard-passive approaches

ABSTRACTConsumers prefer home and community-based long-term care (LTC) services (HCBS) but lack information on those services. We examined the use of community health workers (CHWs) to find and help Medicaid beneficiaries with unmet LTC needs access HCBS compared to standard HCBS outreach approaches. We found that CHWs were very effective at finding persons with greater needs and were better able to help them access a greater range of HCBS services. We also found that five times fewer HCBS beneficiaries helped by CHWs had to use nursing home care services than those not helped by the CHWs despite the fact that their health status was poorer than those not helped by the CHWs. Our study provides evidence of the effectiveness of CHWs for HCBS service awareness and navigation.

Anxiety and Unmet Needs for Assistance With Daily Activities Among Older Adults.

Objective: To examine the potentially bidirectional relationship between anxiety symptoms and unmet needs for assistance with daily activities among older adults. Method: Data came from the National Health and Aging Trends Study, 2011 through 2016 surveys. The study sample consisted of 3,936 Medicare beneficiaries with activity limitations at baseline, aged 65 or older. Cox proportional hazards regression was used to test the proposed relationship between anxiety symptoms and unmet needs for assistance with daily activities. Result: Having unmet needs increased the risk of the onset of anxiety symptoms, and elevated anxiety symptoms increased the risk of incident unmet needs for assistance with daily activities. Conclusion: Anxiety symptoms and unmet needs form a bidirectional relationship. Integrated mental health and community-based long-term care services may help reduce the burden of late-life anxiety disorders and stressful life incidents contributing to disability.

Reaching Out to Rural Caregivers and Veterans with Dementia Utilizing Clinical Video-Telehealth.

Context: A clinical video telehealth (CVT) program was implemented to improve access and quality of dementia care to patients and their caregivers in rural areas. The program was offered as part of an established dementia clinic/geriatric primary care clinic in collaboration with five community-based outpatient clinics (CBOC’s) affiliated with the Tennessee Valley Healthcare System (TVHS) in middle Tennessee. Telehealth support was provided by a physician–social worker team visit. Methods: Telehealth training and equipment were provided to clinic personnel, functioning part-time with other collateral clinical duties. Patients and caregivers were referred by primary care providers and had an average of one to two CVT encounters originating at their local CBOC lasting 20 to 30 min. Clinical characteristics and outcomes of patients and caregivers receiving CVT support were collected by retrospective electronic medical record (EMR) review. Results: Over a 3-year period 45 CVT encounters were performed on patient–caregiver dyads, followed for a mean of 15 (1–36) months. Some 80% patients had dementia confirmed and 89% of these had serious medical comorbidities, took an average of eight medications, and resided at a distance of 103 (76–148) miles from the medical center. Dementia patients included 33% with late stage dementia, 25% received additional care from a mental health provider, 23% took antipsychotic medications, 19% transitioned to a higher level of care, and 19% expired an average of 10.2 months following consultation. Significant caregiver distress was present in 47% of family members. Consult recommendations included 64% community-based long-term care services and supports (LTSS), 36% medications, and 22% further diagnostic testing. Acceptance of the CVT encounter was 98%, with 8770 travel miles saved. Conclusions: CVT is well received and may be helpful in providing dementia care and supporting dementia caregivers to obtain LTSS for high-need older adults in rural areas.

Preferences for home- and community-based long-term care services in Germany: a discrete choice experiment.

Most people prefer to "age in place" and to remain in their homes for as long as possible even in case they require long-term care. While informal care is projected to decrease in Germany, the use of home- and community-based services (HCBS) can be expected to increase in the future. Preference-based data on aspects of HCBS is needed to optimize person-centered care. To investigate preferences for home- and community-based long-term care services packages. Discrete choice experiment conducted in mailed survey. Randomly selected sample of the general population aged 45-64years in Germany (n = 1.209). Preferences and marginal willingness to pay (WTP) for HCBS were assessed with respect to five HCBS attributes (with 2-4 levels): care time per day, service level of the HCBS provider, quality of care, number of different caregivers per month, co-payment. Quality of care was the most important attribute to respondents and small teams of regular caregivers (1-2) were preferred over larger teams. Yet, an extended range of services of the HCBS provider was not preferred over a more narrow range. WTP per hour of HCBS was €8.98. Our findings on preferences for HCBS in the general population in Germany add to the growing international evidence of preferences for LTC. In light of the great importance of high care quality to respondents, reimbursement for services by HCBS providers could be more strongly linked to the quality of services.

Development of quality indicator for adult day services towards promoting the community-based integrated care system in Japan

An introduction: From an international point of view, Japan government have promoted integrated care system in the community-based way. Incentives through the long-term care and medical fee system already promoted collaboration between healthcare facilities and community-based long-term care services, and the new reform of the system in 2012 will reinforce this integration of care. On the other hand, in large cities, long-term care benefit cost are increasing with the increasing elderly population ratio. In Japan, long-term care providers are increasing rapidly in which provide services for elderly people whose care levels are low. It is because they can run the business at a relatively small scale and their income is firm. As a result of this situation, among others, there is a problem of extremely increasing number of the providers in cities. We need the control of the number of these providers through the assessment of the quality of the services they provide. In this research, we try to development of quality indicator for adult day Services towards the community-based integrated care system in O-city. These indicators should be associated with transitions of scores such as ADL and QOL and third parties can use it easily. Short description of practice change implemented: We conducted pilot project at O-city. There have already been 278 providers in O-city and 11,439 people have used their services, but even from the point of the city's scale, these numbers are remarkable in Japan. 178 providers (64.0%) participated in this pilot project. In order to create a draft version of the indicators, we made the committee composed of the city workers, the representatives of long-term care providers, and academic experts. The index is composed of categories, staff support, care techniques, awareness of providers, and awareness of community residents, and 25 items. We asked all the providers participated in this project to submit the data concerning ADL/QOL of all their services users in these indicators and at the two points in 2015 (August and February). Key findings: Through the analysis of the collected data, we choose the 5 indicators (1.the rate of the staffs who participate in training courses in the providers, 2.the rate of staffs who participate in training courses outside the providers, 3.the rate of staffs who is qualified to be a certified care worker, 3.the rate of staffs who is qualified to be a rehabilitation specialist, and 5.the rate of demented people in the users) out of 25 items. From the relationship between this index and the evaluation index scores of shift in 6 months and quality of the daily living functional evaluation of 1,517 users in the participating providers, we found that 3 indicators (2,4,5) were related to an improvement of users. Highlights: The O-city continued the project concerning the evaluation of the qualities and announced the result to the citizens. And the O-city prepares making financial incentive to use the quality evaluation by indicators. Besides the city considers including the strength of cooperation between medical services and long-term care in the indicators from the point of constructing a community-based integrated care system. Conclusion: Japan promotes constructions of community-based integrated care system and its means depends on autonomous local governments. The O-city starts to control the long-term care providers through the evaluation of the quality of the day-service providers and verifies whether the control have an effect on a hold-down on medical and care expenses as one of its outcome. This efforts is seems to be advanced practice in Japan, but we need to make it more common in the future.

Classification trees for identifying non-use of community-based long-term care services among older adults

Home- and center-based long-term care (LTC) services allow older adults to remain in the community while simultaneously helping caregivers cope with the stresses associated with providing care. Despite these benefits, the uptake of community-based LTC services among older adults remains low. We analyzed data from a longitudinal study in Singapore to identify the characteristics of individuals with referrals to home-based LTC services or day rehabilitation services at the time of hospital discharge. Classification and regression tree analysis was employed to identify combinations of clinical and sociodemographic characteristics of patients and their caregivers for individuals who did not take up their referred services. Patients’ level of limitation in activities of daily living (ADL) and caregivers’ ethnicity and educational level were the most distinguishing characteristics for identifying older adults who failed to take up their referred home-based services. For day rehabilitation services, patients’ level of ADL limitation, home size, age, and possession of a national medical savings account, as well as caregivers’ education level, and gender were significant factors influencing service uptake. Identifying subgroups of patients with high rates of non-use can help clinicians target individuals who are need of community-based LTC services but unlikely to engage in formal treatment.

Effects of Visiting Nursing Services in Long-term Care Insurance on Utilization of Health Care

Purpose: This is a comparative study using secondary data from the Korean national long term care (LTC) insurance. Methods: Visiting nursing (VN) service users (n=666) and non-users (n=4,375) were extracted and compared in terms of medical expenditures, length of hospitalization, and annual number of ambulatory care visits to investigate effects of VN services in LTC. Results: Total health care expenditures were compared between the two groups and it was found that VN service users spent about $ 1700 than non-users for their medical costs between 2009 and 2011. The average length of in-hospital stay for VN service users was 19.4 days shorter than that of non-users. However, using VN services did not significantly influence the annual number of ambulatory care visits. Conclusion: The study has found that VN services are effective ways of providing community-based LTC services. We recommend LTC policy makers to further utilize VN services to deliver cost effective health care services.

Community-Based Long-Term Care Services: If We Build It, Will They Come?

This study examines the relationship between caregivers' perception of community-based long-term care (CBLTC) services and the service use. We used first two waves of the longitudinal data set of 1,416 dyads of care recipients and their caregivers in Singapore. Four perceived attributes of LTC services--service quality, convenience, social connectedness, and affordability--were measured on a 5-point scale. Among the four perceived attributes, perceived affordability was significantly associated with future utilization for all types of CBLTC services. Perceived service quality and convenience was significantly associated with center-based LTC services use. Caregivers are critically involved in the decision of using CBLTC services, and their perception of service characteristics is significantly associated with the uptake of CBLTC services. It is important to incorporate both care recipients' and caregivers' needs and preferences when designing and promoting integrated health care delivery models.

Chronic Disease in the Twentieth Century: A History by George Weisz (review)

Reviewed by: Chronic Disease in the Twentieth Century: A History by George Weisz Daniel M. Fox George Weisz. Chronic Disease in the Twentieth Century: A History. Baltimore: Johns Hopkins University Press, 2014. xvi + 307 pp. $29.95 (978-1-4214-1303-7). Weisz’s latest book has strengths and flaws as a result of his having read widely but selectively in pertinent primary and secondary sources. His overarching thesis is that recognition of the increasing problem of chronic disease and the formulation of policy to address it occurred sooner and more thoroughly in the United States than in either France or the United Kingdom. Weisz presents his evidence and argues his thesis in an introduction, ten chapters, and an epilogue. His most original contributions are descriptions, grounded in archival and published primary sources, of policy in the 1920s and 1930s for chronic disease in Massachusetts (pp. 47–54) and New York City (pp. 69–75) and a history of the National Health Survey conducted in 1935–36 and its influence on policy (pp. 77–110). Weisz’s repeated assertions that policy and clinical practice for responding to chronic disease have long been more effective in the United States than in France or the United Kingdom are not persuasive. With a few exceptions late in the book (notably p. 231), he fails to grasp the significant relationship between the politics of achieving and implementing universal coverage and the organization and financing of services for persons with chronic disease. Because the United States has moved more slowly and incrementally toward universal coverage than other industrial countries, American policy for reimbursing physicians and hospitals has, until quite recently, incentivized physicians and hospitals to prioritize intervening in acute manifestations of chronic disease over managing the consequences of these diseases for patients’ health and functional status. Weisz also claims that older Americans have had, for decades, better access to home- and community-based long-term care services than their counterparts in France and the United Kingdom (and perhaps also in Canada, where he lives, but which he mentions only briefly). Many persons who make and study health policy have, however, demonstrated that the United States, unlike the United Kingdom and numerous other countries, has only recently begun to address comprehensively the progressive but intermittent frailty of seniors, especially those who suffer from multiple chronic diseases. Weisz’s claim (p. 172) that the absence of universal [End Page 357] coverage made it easier for leaders in the health sector in the United States to prioritize chronic disease is likely to astonish many knowledgeable readers. Moreover, Weisz repeatedly criticizes this reviewer for overemphasizing the failures of American policy to address chronic disease (pp. 8, 129, 132, 166). I am grateful to him for recognizing that I have written about how and why policy for chronic disease in the United States has failed to maximize patients’ access to care that could maintain and improve the quality of their lives. But he neither identifies nor evaluates the causes to which I attribute this failure: (1) the comparatively slow achievement of universal coverage in this country; (2) the relative absence until recently (compared to numerous other countries) of strong financial incentives to providers of health services to integrate the types and levels of care; and (3) public and private sector financing policy that has incentivized the commercialization of health care since the late nineteenth century. The book also has omissions and misstatements that may, in part, result from inadequate prepublication peer review. An important omission is the contribution of both research and clinical policy in the United Kingdom to influential guidance for policy published initially by the World Health Organization in 1976 as The International Classification of Impairments, Disabilities and Handicaps. (Weisz recognizes but does not name this publication on page 202 and cites a significant article by its principal author, Philip Woods, on page 286.) Errors include confusing the authority of decision makers and staff of the committee appointed by President Franklin D. Roosevelt to write the Social Security Act (p. 82); misstating the history of the U.S. National Science Foundation (p. 151); misunderstanding the history and scope of clinical epidemiology (p. 153); oversimplifying by omission the history...

Person-Centeredness in Home- and Community-Based Long-Term Care: Current Challenges and New Directions

Person-centered care (PCC) has demonstrated to be a viable and preferred model of providing health and institutionalized long-term care services. However, the concept of PCC has not been fully extended to home- and community-based long-term care services (HCBS) for older adults with chronic conditions. This review highlights the need for PCC in HCBS and suggests that social workers may play a role in overcoming cultural and structural barriers to extending PCC to HCBS that include: the fragmentation of the industry, financial structures, regulation of services, and paternalism in policy and practice. Recommendations for practice, policy, and research are provided.