Consumer-directed Care Models Research Articles

Heuristics, Biases, and Decisions in Resource Allocation for Home Care Packages under Consumer Directed Care: A Systematic Review and Thematic Synthesis

Consumer-directed care (CDC) is a policy solution for quality deficiencies in aged care where seniors accessing care services are empowered with full choice and flexibility over their service packages. Various programs have been developed using this policy approach around the world, and implementation has invoked a mixture of responses. While consumer organisations welcome a policy direction providing additional choice, there is a concern that this policy complicates the decision-making process, leading people to rely on “rules of thumb” (heuristics) that may not reflect their best interests. Behavioural science provides a lens for looking at heuristics and biases that may occur during complex decision making, particularly as people age. Objective. To explore the presence and influence of heuristics and biases on the decision-making processes of older people receiving home care services under a CDC model. Method. Qualitative systematic review involving systematic searching of PubMed, MEDLINE via Ovid, Embase via Elsevier, CINAHL via Ebsco, PsycINFO via Ovid, Web of Science, Scopus, and EconLit, from inception until 14th April 2022 was undertaken. Identified articles were deduplicated, screened, and extracted for information relevant to the research question using PRISMA guidelines. Data extraction considered descriptive data and metadata including study type, participants, overall objectives, chosen methodologies, and their relationship to the research question. The variety of study types prompted a thematic synthesis to achieve greater comprehension of the existing knowledge base. Results. Descriptive categories were analysed to reveal five themes relevant to the presence and influence of heuristics and biases in decisions made by older people when allocating home care resources. Principally, CDC is implemented to afford autonomy but is complicated by the decision-making environment. Choice and decision making are both specific to the individual, and the processes employed for decision making vary over the life-course. Decision quality can be improved through the identification and mitigation of complicating factors. More research is needed to understand how modifications can assist decision making and improve health outcomes.

Real World Challenges in Delivering Consumer Directed Care to Enhance Nursing Home Residents’ Well Being

ABSTRACT Objectives The aim of this study was to use the ADKAR model of organizational change to gain an understanding of why a training program designed to equip staff with the skills to provide a Consumer Directed Care (CDC) model in nursing homes produced little change in the outcome variables, including resident quality of life. Methods We collected and analyzed various forms of site-specific data including CDC implementation plans developed by staff trained in 21 facilities, and their training facilitators’ records. Results Staff trained in the principles of CDC produced well-developed, facility-specific plans to introduce a CDC model of care, yet they faced many barriers to the implementation of these plans. These barriers were spread across multiple stages of the ADKAR model and included staff turnover (including managers), lack of engagement by management, lack of or inconsistent availability of a CDC champion, and disruptions to the training program. Conclusions We identified several organizational factors contributing to the failure of the training program to produce anticipated changes. Clinical Implications Without organizational commitment and full management support, attempts to implement CDC training programs are likely to fail, leading to negative consequences for residents’ autonomy and control over how they are cared for.

Perspectives and practices associated with consumer-directed care in Australia: Synergies and tensions in supporting planning and delivery of home care for older people with dementia.

This study used a qualitative, cross-sectional design to address a gap in understanding the perspectives and practices of care planners and case managers in supporting consumer- directed care (CDC) for community dwelling people living with dementia. Semi-structured telephone interviews were conducted with a convenience sample of n=16 planners and managers from seven providers of the Australian home care packages (HCP) program in NSW (Australia). All interviewees described the aspirations of supporting choice within CDC as synergistic with their values and with person-centred care. Some described new flexibilities within the more open-ended planning conversations enabled by CDC. However, most acknowledged their capacity to enable choice for clients with dementia was limited by the capped care budgets, as well as the skills and time needed to support choice and decision- making. Organisational practice changes associated with the shift to a market-based system were also perceived as limiting the capacity to support choices. Reducing centralised systems, increasing individual budgets and improving staff capacity to support decision-making by people with dementia may help to improve this situation. However, results suggest a deeper need to re-evaluate whether the CDC model is the most appropriate for supporting the rising numbers of people with dementia to age well in place.

Consumer Directed Care and Resident Quality of Life: How Leadership and Organizational Factors Impact on Success

ABSTRACT Previous studies have demonstrated inconsistency in the effectiveness of staff training programs in consumer directed care (CDC) as a means of enhancing the quality of life (QoL) of residents. The aim of this study was to investigate why this might be the case. We analyzed disaggregated cluster-by-cluster resident QoL outcomes after nursing home staff completed a CDC training program. In total, 33 nursing homes (11 clusters) participated in the study. As with previous studies, the outcomes across nursing homes were inconsistent – QoL improved at some sites but at many it remained stable or declined. Analysis of facilitator notes from the most and least successful clusters indicated that a lack of organizational support, for both the training and subsequent practice of CDC, was potentially the key barrier to effective implementation of training and so improvement in resident QoL. These findings demonstrate that all levels of aged care organizations – on the floor staff, managers and senior staff – need to fully support a CDC model of care to optimize outcomes for residents. Staff require training in CDC as well as long-term culture change within the nursing home so that training can be translated into practice.

Policy Design and Consumer Direction: Cross-country Comparisons on Consumer-directed Care Programs

Objectives: The consumer-directed care (CDC) program aims to maximize health outcomes by offering older adults more control, choice, and flexibility over the care services they received. However, countries may operate CDC programs in different ways based on heterogenous sociostructural systems. We proposed a comparative framework to evaluate three dimensions of CDC—control and direct services, variety of service options, and information and support—and analyzed how countries varied in their policy design to achieve consumer direction. Methods: Using cross-national document analysis, we analyzed eleven CDC programs from seven selected countries (Netherlands, United States (US), United Kingdom (UK), Germany, China, Australia, and Spain) with five CDC care regimes. A total of fourteen indicators capturing three dimensions of CDC programs was developed. We further used these indicators to evaluate and compare similarities and differences of policy features across countries using descriptive statistics and graphical approaches. Results: CDC programs in the Netherlands, Arkansas, and the UK ranked at the top in consumer direction. All countries except Germany employed a “service-based” principle in determination of service type. Training care workers was in the most widespread use to assure quality of care. Merely the UK and Germany integrated CDC and conventional agency care without restrictions. Representative with relevant support was only available in the UK and Netherlands. Discussion and Implication: CDC models involve multi-faced aspects, rather than dichotomies and discrete entities. Implications include the need for a systematic reflection with our developed framework and enriching variety of service options to promote consumer direction.

Has consumer-directed care improved the quality of life of older Australians? An exploratory empirical assessment.

To assess the impact of a Consumer Directed Care (CDC) model of service delivery on the quality of life of older people receiving home care packages. Quality of life was assessed using validated instruments. The relationship between quality of life and length of time exposed to CDC was examined using descriptive statistical and multivariate regression analyses. Consenting older adults (n=150) in receipt of home care packages participated. Quality of life and capability scores were higher for older people in receipt of a CDC model of service delivery for <12months compared to those receiving the model of care for longer, although this difference was not statistically significant. However, older people with more recent exposure to CDC indicated a stronger capability to do things that made them feel valued. Extended longitudinal follow-up is needed to facilitate a detailed examination of the relationship between the evolution of CDC and its longer-term influences on quality of life.

Consumer directed care aged care reforms in Australia since 2009: A retrospective policy analysis

In 2009, the Australian federal government used the projected rise in aged care expenditure and changing societal attitudes to justify the decision to overhaul the funding for aged healthcare services. A major feature of the reforms was the introduction of a consumer directed care (CDC) model. This followed the UK, Sweden, Canada and the USA who had already implemented CDC to some degree. The CDC model transferred aged care decisions from providers to consumers. This promised to create a competitive market system, resulting in decreased costs, increased quality and increased consumer satisfaction of aged healthcare services. Advocacy services were also reformed to address market failures. These changes were achieved by engaging key actors throughout the policy cycle, giving perceived legitimacy and transparency; and commissioning reviews with restricted scope and at calculated times, limiting their ability to produce negative criticism. In July 2018, the federal government gained full funding and responsibility for aged care with the support of key stakeholders and multiple reviews, yet with little objective data on the benefit of the reforms. This analysis highlights the power of the policymaking process in creating policies.

Home Modification Service Delivery in Australia

In Australia, a patchwork of services provide home modifications, each with varying approaches and service guidelines. This context is rapidly changing with consumer directed care models impacting the aged care and disability sectors. A study investigating satisfaction with service delivery for 31 clients of major home modification services is presented to illustrate home modification practice in Australia. The findings indicate overall satisfaction with home modification services, but also revealed areas for improvement and inequalities in service provision. This included the need for more choice in design, materials and products and the impact of housing tenure, where renters reported lower satisfaction.

Anticipated Engagement in a Village Organization for Aging in Place

Although older adults prefer maintaining residence independently in the community as they grow older it is not always possible due to impairments, isolation, and changing health needs. Villages, an emerging consumer-directed care model providing social engagement and services, support aging in place. To be viable organizations villages must attract and enroll sufficient numbers of members. This study examined factors associated with older adults anticipated engagement as a village member. Using a cross-sectional survey design community residing older adults (N = 193) identified predisposing, enabling, and need factors associated with anticipated engagement. Participants rated anticipated engagement between “Slightly Unlikely” and “Likely” (Mean = 2.71, SD = 1.31). A model including predisposing and enabling factors produced the best overall fit [−2 Log likelihood = 246.514, χ2(8) = 20.414, p. = .008] correctly classifying 61.1% of cases and explaining 13.4% of the variance according to the Nagelkerke R2 statistic. Older adults who engage in preventative health behaviors may be predisposed to joining a village as well as those who are already engaging in supportive acts of neighboring. Villages might consider these factors in designing outreach and service programing. Future research should identify how factors such as income and personal health practices contribute to interest in village membership.

Consumer-directed care and the relational triangle

PurposeFollowing a recent government initiated change to a consumer-directed care model across the Australian community aged care sector, the purpose of this paper is to explore frontline home support workers’ perceptions of relational changes with clients in power and subordination within the triadic relationship between employer, employee and client.Design/methodology/approachContextual interviews were held with managers (n=4), coordinators (n=10) and semi-structured face-to-face interviews with support workers (n=17) in three organizations. Interview transcripts were analyzed.FindingsSome workers did not perceive a power change in their relationships with clients. Others perceived minimal change but were concerned about the incoming client generation (baby boomers) that were more aware of their rights. Others felt subordinated to the client, perceived a loss of control or that felt treated like an employee of the client. Consistent with the philosophy of consumer-directed care, senior staff encouraged clients to treat workers in this way.Research limitations/implicationsFurther research is recommended on worker and client perceptions of relationships within the context of a consumer or client focused model.Practical implicationsA clear and realistic understanding of the locus of power within a triadic relationship by all actors is important for positive workplace outcomes.Social implicationsThe increasing ageing population makes it essential that workers’ relationships with clients and with their organization are unambiguous.Originality/valueThis study makes a contribution to theories about change and power transfer in the implementation of consumer-directed care through the perceptions of support workers. Examination of power and subordination transfer through the perceptions of the actors of rather than through the prism of organizational policy deepens the understanding of frontline service work and relationships.

Investigating consumers' and informal carers' views and preferences for consumer directed care: A discrete choice experiment

Consumer directed care (CDC) is currently being embraced internationally as a means to promote autonomy and choice for consumers (people aged 65 and over) receiving community aged care services (CACSs). CDC involves giving CACS clients (consumers and informal carers of consumers) control over how CACSs are administered. However, CDC models have largely developed in the absence of evidence on clients' views and preferences. We explored CACS clients' preferences for a variety of CDC attributes and identified factors that may influence these preferences and potentially inform improved design of future CDC models. Study participants were clients of CACSs delivered by five Australian providers. Using a discrete choice experiment (DCE) approach undertaken in a group setting between June and December 2013, we investigated the relative importance to CACS consumers and informal (family) carers of gradations relating to six salient features of CDC (choice of service provider(s), budget management, saving unused/unspent funds, choice of support/care worker(s), support-worker flexibility and level of contact with service coordinator). The DCE data were analysed using conditional, mixed and generalised logit regression models, accounting for preference and scale heterogeneity. Mean ages for 117 study participants were 80 years (87 consumers) and 74 years (30 informal carers). All participants preferred a CDC approach that allowed them to: save unused funds from a CACS package for future use; have support workers that were flexible in terms of changing activities within their CACS care plan and; choose the support workers that provide their day-to-day CACSs. The CDC attributes found to be important to both consumers and informal carers receiving CACSs will inform the design of future CDC models of service delivery. The DCE approach used in this study has the potential for wide applicability and facilitates the assessment of preferences for elements of potential future aged care service delivery not yet available in policy.

The Perspectives of Older Greek-Australians Toward Changes in the Nature of Family Support: Implications for Family Care Policies

Internationally, public policies encourage “aging in place,” and the majority of older Australians requiring care in the community receive informal care, supplemented by publicly subsidized formal services. The effect of contemporary social changes on informal care in aging migrant communities is poorly understood. This articles explores the perceptions of older Greek-Australians toward changes in the nature of family support. Bicultural and bilingual researchers carried out in-depth interviews (n = 27) and five focus groups (n = 63 total participants) with older Greek-Australians in modern Greek. While “cultures of care” remain among Greek-Australian families, the means for a family to assist have shifted, and these compromises are met with considerable powerlessness among older Greek-Australians. Implications for policy include the need to better involve older migrants and their families in decisions about their care needs, potentially involving consumer-directed care models. Service providers may also need to adopt the use of new technologies to communicate with increasingly time-pressured family members.

Stakeholder Perspectives on Policies to Support Family Caregivers of Older Adults With Dementia

Persons with dementia are often excluded from consumer-directed home- and community-based service programs because they cannot direct their own care. Surrogates are permitted in some states, thereby allowing program participation. This study explored family caregiver perspectives on policies that support family needs related to providing care to relatives with dementia, access to home- and community-based services, and the potential benefits of a consumer-directed service model. The authors conducted three focus groups with family caregivers (N = 25) in eastern Missouri who were recruited through support groups and service providers. Family caregivers reported difficulty in acquiring services, high levels of psychological and physical stress, greater need for caregiving supports, and a desire for public policy change to support caregiving families. Caregivers cited differences in knowledge, family relationships, and health and employment circumstances as reasons why they would prefer a traditional case management model, a consumer-directed care model, or a cash and counseling model. Family caregivers suggested that surrogate decision making within consumer-directed care should, at minimum, be an available option. Findings from this study offer initial support for the advancement of family-centered care models in home- and community-based dementia care practices and policies to support the caregiving efforts of families.

Consumer-directed community care: race/ethnicity and individual differences in preferences for control.

Even though consumer-directed care models are being advocated for use among elder populations, there are few data on the extent of elder interest in participating in the management of community long-term-care services, who they want involved in making these decisions, or their perceptions regarding the relative importance of different service choices. In addition, little is known about how elder preferences for consumer direction may vary by race/ethnicity. With use of a cross-sectional research design, a sample of 731 elders including 200 African American, 200 Chinese, 131 Latino, and 200 White Western European American elders was investigated. New measures were created to assess level of control desired by elders in different areas of community long-term-care service delivery and preference for consumer direction. Multivariate analyses found significant differences between and within race/ethnic groups for preferences for levels of consumer-directed care. Study findings suggest that consumer direction occurs along a continuum, with elders desiring control over some service areas but not others, and the importance of recognizing heterogeneity within racial/ethnic groups regarding consumer-directed care.

Austria's new attendance allowance: a consumer-choice model of care for the frail and disabled.

Austria's new social welfare provision, an attendance allowance, adopted in 1993, is a prototype for a consumer-directed care model for persons who are frail or disabled. This article describes the background to and provisions of the new legislation, including the unique political interests from the left and the right that converged to facilitate its passage. The author discusses eligibility criteria, the consumer autonomy principles underlying the model, and the impacts and implications anticipated. Such a model has been mentioned as an option for states considering creative expansion of long-term care provisions in the United States.