Long-term Care Providers Research Articles

Cross-country price comparison of institutional long-term care: In search of suitable data

Abstract Background In European ageing societies, the national expenditure on institutional long-term care (LTC) has been growing for decades, currently exceeding 1% of the GDP in many countries. At the same time, however, comparative analyses of (day) prices in the nursing and residential care facilities (NRCFs) are still lacking. The data reported by international databases vary substantially in the services they cover which makes cross-country comparisons very difficult. Methods We combine publicly available data from Eurostat (System of Health Accounts), OECD and national sources on the number of recipients of LTC in NRCFs, the number of beds in NRCFs and the expenditure on LTC in NRCFs in over 20 European countries. Our aim is to compute internationally comparable daily prices of LTC in NRCFs using gross-costing approach. We first validate the data by cross-checking and documenting which health care functions and providers are reported by each country. Second, based on that we identify countries with comparable data and, third, perform a cross-country comparison of the daily spending on LTC in NRCFs. Results The reported data vary substantially with respect to their coverage. For instance, while some countries include NRCFs for all disabled people at all ages, others focus only on the NRCFs for the elderly. The ways the beds and the recipients are counted also show substantial variation. Moreover, we found inconsistencies in the reported numbers not only between but also within countries. Conclusions The considerable cross-country diversity in the LTC provision within the NRCFs poses inevitable challenges to international standardised reporting. Our analysis shows, however, that at least some of the challenges can be overcome by, e.g. improving the consistency of the reported numbers at the country level. Key messages • A consistent definition application markedly improves the comparability of data on LTC in NRCFs. • Given the rising demand for and economic importance of the LTC sector standardised data on NRCF services are greatly needed.

Telemedicine Use During the COVID-19 Pandemic by Office-based Physicians and Long-term Care Providers.

This report examines telemedicine use by office-based physicians and long-term care providers in the United States, stratified by electronic health record use and by provider or practice size. Further, it examines differences in telemedicine use before and after the COVID-19 pandemic onset among office-based physicians and assesses telemedicine use during the first year of the COVID-19 pandemic for long-term care providers. Nationally representative estimates in this report are derived from data collected in the 2019 and 2021 National Electronic Health Records Survey, which assesses characteristics of office-based physicians, and the 2020 National Post-acute and Long-term Care Study, which assesses characteristics of adult day services centers and residential care communities. Measures include telemedicine using audio with video or web videoconference for patient care, electronic health record use for more than accounting or billing purposes, and size of physician practices and long-term care providers. In 2021, 80.5% of physicians in office-based settings used telemedicine for patient care, up from 16.0% in 2019. In 2020, 20.5% of adult day services centers and 44.5% of residential care communities used telemedicine to care for users with COVID-19. Office-based physicians, adult day services centers, and residential care communities that used electronic health record systems were more likely to also use telemedicine compared with those not using electronic health records. Large practices and providers were more likely to use telemedicine compared with small practices and providers. Findings from this report describe telemedicine use among office-based physicians and long-term care providers. Practices and providers that used electronic health records and were larger were more likely to also use telemedicine for patient care during the COVID-19 pandemic.

Long-Term Care Use Among Older Migrants in the Netherlands: What to Expect in the Next Decade?

ABSTRACT The number of older adults in the Netherlands is growing rapidly, and an increasing share of them is foreign-born. This may have implications for long-term care (LTC) demand. This study provides insights into older migrants’ current and future use of LTC provisions under the Dutch long-term care act (LTCA). We distinguish three types of LTC and six groups of older migrants and analyze register data of all foreign-born older adults. Descriptive statistics for the 2016–2022 period and logistic regression analyses show considerable heterogeneity regarding the LTC-services used and the origin of care users. Most notably, Moroccan and Turkish older adults are least likely to use residential care and more likely to use personal care budgets. By combining our models’ results with population projections, we project that older migrants’ use of home-based care and personal budgets will increase rapidly in the next decade. Migrants with western and Surinamese origin will most often use LTC. Although the demand for residential care will rise less markedly, residential care will remain most used by older migrants under the LTCA. The rising demand for home-based care calls for policy efforts accommodating flexibility, room for differences, and grounds for establishing trustworthy relationships between all involved actors.

Overview of Post-acute and Long-term Care Providers and Services Users in the United States, 2020.

This report presents national results from the National Post-acute and Long-term Care Study to describe providers and services users in seven major settings of paid, regulated post-acute and long-term care services in the United States. Data are from the 2020 National Post-acute and Long-term Care Study, which includes surveys of adult day services centers and residential care communities and administrative data from the Centers for Medicare and Medicaid Services on home health agencies, hospices, inpatient rehabilitation facilities, long-term care hospitals, and nursing homes. The findings show variation in characteristics of the seven post-acute and long-term care settings. About 68,150 providers served roughly 7.3 million people in the United States; about one-half of these providers were residential care communities, and about one-quarter were nursing homes. The Northeast had a higher percentage of adult day services centers than other settings, the Midwest had a higher percentage of nursing homes, the South had a higher percentage of long-term care hospitals, and the West had a higher percentage of residential care communities. Among the settings, more registered nurses were employed in inpatient rehabilitation facilities and long-term care hospitals, and more licensed practical nurses in home health agencies and long-term care hospitals. The most common services were skilled nursing and therapeutic services. Adult day services centers had the highest percentage of users younger than age 65, while nearly one-half of hospice and nursing home users were age 85 and older. Adult day services centers had the highest percentage of other non-Hispanic and Hispanic users among the settings. The percentage of users with selected diagnoses and activities of daily living difficulties varied by setting. The providers described in this report comprise a large share of the U.S. post-acute and long-term care industry. This report provides the most recent nationally representative information on these providers and services users and updates findings from previous National Center for Health Statistics reports.

A maze of responsibility

This paper is an attempt to deconstruct, formally decode the notion of responsibility frequently appearing in the process of deinstitutionalisation and long-term care provision. It is a Kafkian predicative category of subordination. Its value is determined by its two objects. "For what" we are responsible constitutes the substance of responsibility, "to what" constitutes its form and sense. By examining the substance of responsibility—for acts, things and people, we have derived the basic parameters, conditions constitutive of responsibility: loss (negative consequences), alienation, reification, removal of will and ascribing. Investigating the form of responsibility, of that to which we are responsible, we have schematically divided instances of responsibility into hierarchic and horizontal, as well as into reflexive and transient. Intricacies of responsibility to authorities, public, community as well as to near ones and the self are explored in their action and contemplative properties. Deinstitutionalisation on the one hand restores civic responsibility to the service users, on the other it transmutes its very conditions. The imperative is to restore their will capacity, not to ascribe acts to stigma, allow reappropriation and humanisation and to put the emphasis on achievement and success. In the case of the key worker, we demonstrate a new pattern of professional responsibility, in which acts are actors' responsibility, while helpers are responsible for service delivery, their own acts and for teamwork that will uphold the user's emancipation. In the transition to community, subordinative responsibility is being transformed into everyday responsiveness and common responsibility for humanity.

Estimation of private-use prices of at-home care services in Japan: Data from a survey of housekeeper employment agencies

ABSTRACT This study examined housekeeper referral agencies’ operations in Japan, their services, and fee standards. This promoted an estimation of the standard price of housekeeping services in Japan if insurance coverage was excluded. Questionnaires were distributed to 399 housekeeping agencies whose addresses were available on the website of the Japan Association of Nursing and Welfare Placement Agencies as of October 2022, and 101 agencies responded (response rate: 25.3%). Surveys were completed in February–March 2023. Two-thirds (65%) of the housekeeper placement agencies had a long-term care (LTC) insurance office. Housekeeper referrals were mostly for 1–4 h; the fee varied according to city size and service provider type, which tended to be higher in larger cities. The fees were lower for attached LTC providers than for stand-alone providers. Most managers (60%) of housekeeper referral agencies rated their fees as ‘somewhat low’ or ‘very low’, requesting an increase in users’ burden and housekeepers’ compensation. LTC insurance keeps the prices of services provided by housekeeper referral agencies low. In the future, daily living support services for the lightly insured may be excluded from LTC insurance coverage in Japan, and the demand for housekeeper agencies’ services is expected to increase.

Development of Shared Decision-Making Toolkit in Long-Term Care for People with Dementia.

This study develops a toolkit to enhance Shared Decision Making (SDM) in long-term care (LTC) for older people with dementia. Recognizing their right to participate in care decisions, the study adopts a co-production approach for toolkit development, including needs assessment, scoping review, guideline creation, and a pilot study. The toolkit, targeting LTC providers and users (people with dementia and their caregivers), features an image-based menu for easier understanding and decision-making in care choices and educational materials for users. Designed for direct clinical use, the toolkit aims to improve healthcare equity in LTC settings, offering a practical solution for policymakers to incorporate SDM in long-term care practice.

Patient versus Provider Incentives in Long-Term Care

How do patient and provider incentives affect the provision of long-term care? Our analysis of 551,000 nursing home stays yields three main insights. First, due to limited cost-sharing, Medicaid-covered residents prolong their nursing home stays instead of transitioning to community-based care. Second, when facility capacity binds, nursing homes shorten Medicaid stays to admit more profitable out-of-pocket private payers. Third, providers react more elastically to financial incentives than patients. Thus, targeting provider incentives through alternative payment models, such as episode-based reimbursement, is more effective than increasing patient cost sharing in facilitating transitions to community-based care and generating long-term care savings. (JEL H51, H75, I11, I13, I18, I38, L84)

Quality of life outcomes for informal carers of long-term care service users in Austria, England and Finland

PurposeThe provision and funding of long-term care (LTC) for older people varies between European countries. Despite differences, there is limited information about the comparative performance of LTC systems in Europe. In this study, we compared quality of life (QoL) of informal carers of home care service users in Austria, England and Finland.MethodsInformal carers were surveyed in Austria, England and Finland. The study data (n = 835) contained information on social care-related quality of life (SCRQoL) associated with the ASCOT-Carer measure, and characteristics of carers and care recipients from each country. We applied risk-adjustment methods using a fractional regression model to produce risk-adjusted SCRQoL scores for the comparative analysis. In a sensitivity analysis, we applied multiple imputation to missing data to validate our findings.ResultsWe found that the mean values of the risk-adjusted SCRQoL of informal carers in England were 1.4–2.9% and 0.3–0.5% higher than in Finland and Austria, and the mean values of the risk-adjusted SCRQoL of carers in Austria were 0.8–2.7% higher than in Finland. Differences in the mean values of the country-specific risk-adjusted SCRQoL scores were small and statistically non-significant. English informal carers were less healthy and co-resided with care resipients more often than carers in Austria or Finland.ConclusionSmall differences between the risk-adjusted SCRQoL scores between Austria, England and Finland are consistent with the observation that the countries provide different types of support for informal carers. Our results help local and national decision-makers in these countries to benchmark their informal care support systems.

Caregivers' experience of caring for family members with complex health needs in Latvia.

The article examines the experiences of family caregivers engaged in the provision of long-term care for their relatives with complex health needs within the Latvian context. Semi-structured interviews were conducted with seven caregivers who provide care in cases of dementia, depression, schizophrenia, opioid use, Down syndrome and mild cognitive impairment. A thematic analysis of interview transcripts revealed common themes, such as the initial experiences when encountering a family member's disorder and the subsequent reactions, as well as the quest for support and resources. Variations mainly centered around differences in formal aspects and childhood experiences of care. Caregivers reported risk factors such as guilt, lack of support from family and friends, financial difficulties, deficiency of professional care and ignoring the caregiver's own needs. Awareness of personal resources, values and limits, coping with personal stigma and improved overall quality of life were identified as protective factors. The findings underscore several preventive measures that social and mental health services could implement to mitigate the adverse effects of caregiving on caregivers' lives.

Youth Caregivers of Adults in the United States: Prevalence and the Association Between Caregiving and Education

A growing proportion of individuals adopt family caregiving roles. Family caregivers are the primary providers of long-term care in the United States yet limited federal policy supports exist, despite the known negative impacts of caregiving. There is also limited information about the prevalence of youth/young adult caregivers and the impacts of caregiving at formative ages in the United States. Our objective is to estimate the prevalence of youth caregivers and examine the association of caregiving with educational investments. We use the American Time Use Survey (2013–2019) to identify and describe youth caregivers (aged 15–18) and young adult caregivers (aged 19–22) and compare them with non-caregiving peers. We estimate that there are approximately 1,623,000 youth caregivers and 1,986,000 young adult caregivers, corresponding to 9.2% and 12.7% of these age groups, respectively. However, there is a wide range in the estimated prevalence per year, from approximately 364,000 to 2.8 million youth caregivers and from 353,000 to 2.2 million young adult caregivers, depending on caregiver definition. Unlike adult caregivers, we find that young men and women were nearly equally likely to provide care. We also find that non-White individuals are disproportionately represented as youth caregivers. Compared with non-caregiving peers, both youth and young adult caregivers are less likely to be enrolled in school and, among those enrolled in school, spend significantly less time on educational activities. Considering the association of caregiving among youth/young adults and education, policies supporting youth and young adult caregivers are critical.

The Effect of Informal Caregiving on Depression: An Asymmetric Panel Fixed-Effects Analysis of In-Home and Out-Of-Home Caregivers Across Europe

ABSTRACT Previous research has shown that providing intensive informal care can have a negative effect on an individual’s mental health. However, few studies have been able to draw a precise comparison between the experiences of in-home and out-of-home caregivers. This study used data from 16 countries collected from 2011–2019 as part of the Survey of Health, Ageing and Retirement in Europe (SHARE) to conduct asymmetric panel fixed-effects models that examined within-person variation in depression scores after a respondent started providing daily or almost daily personal care either inside or outside of their home. The results substantiated previous findings that in-home caregivers experience more pronounced increases to their reported depressive symptoms after starting to provide daily personal care than do out-of-home caregivers. In addition, in-home caregivers in countries with greater governmental responsibility for long-term care provision (The Northern and Central Clusters) reported fewer increases to their depressive symptoms after starting to provide care than caregivers in countries where long-term care responsibility predominantly rests on families (The Southern and Eastern Cluster). Further, Northern Cluster countries most successfully shrank the pool of out-of-home care providers. Together, these findings underscore the context-specific nature of caregiver wellbeing.

Does Assisted Living Provide Assistance And Promote Living?

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have worsened; regulations have become complex; the need for consumer support, education, and advocacy has grown; and financing and accessibility have become insufficient. Together, these factors have limited the extent to which today's assisted living adequately provides assistance and promotes living, with negative consequences for aging in place and well-being. This Commentary provides recommendations in four areas to help assisted living meet its promise: workforce; regulations and government; consumer needs and roles; and financing and accessibility. Policies that may be helpful include those that would increase staffing and boost wages and training; establish staffing standards with appropriate skill mix; promulgate state regulations that enable greater use of third-party services; encourage uniform data reporting; provide funds supporting family involvement; make community disclosure statements more accessible; and offer owners and operators incentives to facilitate access for consumers with fewer resources. Attention to these and other recommendations may help assisted living live up to its name.

Does the Design of Welfare Programs Stipulate Nursing Home Utilization? A Comparative Analysis of Long-Term Care Systems in Japan and Germany

Abstract Japan and Germany are both facing a rapidly aging population and have similar social insurance-based long-term care systems. However, there are significant differences in utilization and costs. This paper presents a microeconomic decision model validated by regression analysis, Blinder-Oaxaca decomposition, and Data Envelopment Analysis to contrast the utilization patterns in the Japanese and German long-term care sectors. The design of the welfare programs for low-income families has been identified as one of the main reasons. In Germany, the welfare system leads to a demand curve for nursing home care that is comparable to that of an inferior good which makes external long-term care in nursing homes the more attractive, the poorer the respective households are. In addition, the resulting inelastic demand of the population groups in need of social benefits seem to reduces competition among Germany’s long-term care providers, which is associated with a loss of efficiency in how they use production factors. In Japan, this negative outcome is avoided by a comfort segmentation in the nursing home market.

‘Sit down and thrash it out’: opportunities for expanding ethics consultation during conflict resolution in long-term care

Objective: To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution. Design: An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA). Results: Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half of facilities lack a formal dispute mediation policy. Only five respondents have called an ethics consult for assistance. Conclusion: Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff.

Air pollution and the burden of long-term care: Evidence from China.

We examine the causal effects of PM2.5 exposure on the burden of long-term care (LTC) by matching a satellite-based PM2.5 (particulate matter smaller than 2.5micrometers (μm) in diameter) dataset with a nationally representative longitudinal study in China from 2011 to 2018. We find significant adverse effects of PM2.5 exposure-instrumented by thermal inversions-on the LTC burden. A 10μg/m3 increase in annual PM2.5 exposure increases average monthly hours of LTC and the associated financial costs by 28h and CNY 452, respectively. The effects are greater for those who had never smoked nor experienced severe PM2.5 pollution (annual average PM2.5>35μg/m3) in the previous 5years. We also find that as PM2.5 increases, chronic diseases, particularly cardiovascular diseases, could lead to a higher likelihood of LTC dependency but reduce the total hours and costs of LTC provision. Finally, we find that PM2.5 reduces the total years of LTC need, suggesting that PM2.5 increases LTC costs by increasing the severity of LTC dependency, rather than the duration of LTC need. Our findings can assist policymakers in planning for LTC provisions and clean air policies.

A Cross-Sectional Study of Nurse Turnover in Residential Care Communities.

We examine what facility characteristics are associated with nurse turnover in residential care communities (RCCs). This is a cross-sectional study using the 2018 National Study of Long-term Care Provider Public Use File. There were 3331 RCCs (unweighted n = 272) represented when examining registered nurse (RN) turnover and when examining aide turnover there was a weighted sample of 13,676 RCCs (unweighted n = 68). RN turnover was 72% (95% confidence interval (CI) 59%, 84%), 52% reported 100% turnover. Aide turnover was 48% (95% CI 43%, 53%); 11% reported 100% turnover. We examined ownership and facility type, job design, economic, and working environment factors related to turnover. Using multivariate linear regression, non-profit RCCs had 25 percentage points lower RN turnover (95% CI: -44.46, -4.31) and 9.7 percentage points lower aide turnover (95% CI: 18.8, -0.6) compared to for-profits. We find larger RCCs had lower aide turnover.

Cohort profile: The ENTWINE iCohort study, a multinational longitudinal web-based study of informal care.

Informal care is a key pillar of long-term care provision across Europe and will likely play an even greater role in the future. Thus, research that enhances our understanding of caregiving experiences becomes increasingly relevant. The ENTWINE iCohort Study examines the personal, psychological, social, economic, and geographic factors that shape caregiving experiences. Here, we present the baseline cohort of the study and describe its design, recruitment methods, data collection procedures, measures, and early baseline findings. The study was conducted in nine countries: Germany, Greece, Ireland, Israel, Italy, the Netherlands, Poland, Sweden, and the United Kingdom. The study comprised a web-based longitudinal survey (baseline + 6-month follow-up) and optional weekly diary assessments conducted separately with caregivers and care recipients. From 14 August 2020 to 31 August 2021, 1872 caregivers and 402 care recipients were enrolled at baseline. Participants were recruited via Facebook and, to a lesser extent, via the study website or caregiver/patient organisations. Caregiver participants were predominantly female (87%) and primary caregivers (82%), with a median age of 55 years. A large proportion (80%) held at least post-secondary education, and two-thirds were married/partnered. Over half of the caregivers were employed (53%) and caring for a person with multiple chronic conditions (56%), and nearly three-quarters were caring for either a parent (42%) or a spouse/partner (32%). About three-quarters of care recipient participants were female (77%), not employed (74%), and had at least post-secondary education (77%), with a median age of 55 years. Over half of the care recipients were married/partnered (59%), receiving care primarily from their spouses/partners (61%), and diagnosed with multiple chronic conditions (57%). This study examining numerous potential influences on caregiving experiences provides an opportunity to better understand the multidimensional nature of these experiences. Such data could have implications for developing caregiving services and policies, and for future informal care research.

Nursing home closures and access to post-acute care and long-term care services in rural areas.

Nursing home closures have raised concerns about access to post-acute care (PAC) and long-term care (LTC) services. We estimate the additional distance rural residents had to travel to access PAC and LTC services because of nursing home closures. We identify nursing home closures and the availability of PAC and LTC services in nursing homes, home health agencies, and hospitals with swing beds using the Medicare Provider of Services file (2008-2018). Using distances between ZIP codes, we summarize distances to the closest provider of PAC and LTC services for rural and urban ZIP codes with nursing home closures from 2008 to 2018 and no nursing homes in 2018. Compared to urban ZIP codes, rural ZIP codes experiencing nursing home closure had higher distances to the closest nursing home providing PAC (6.4 vs. 0.94 miles; p < 0.05) and LTC services (7.2 vs. 1.1 miles; p < 0.05), and these differences remain even after accounting for the availability of home health agencies and hospitals with swing beds. Distances to the closest providers with PAC and LTC services were even higher for rural ZIP codes with no nursing homes in 2018. About 6.1%-15.7% of rural ZIP codes with a nursing home closure or with no nursing homes had no PAC or LTC providers within 25 miles. Nursing home closures increased distances to nursing homes, home health agencies, and hospitals with swing beds for rural residents. Access to PAC and LTC services is a concern, especially for rural areas with no nursing homes.

Experience and perceptions of Social Prescribing interventions; a qualitative study with people with long-term conditions, link workers and health care providers

Background Long-term conditions (LTC) are a leading cause of reduced quality of life and early mortality. People with LTC are living longer with increasing economic and social needs. Novel patient centred care pathways are required to support traditional medical management of these patients. Social Prescribing (SP) has gained popularity as a non-medical approach to support patients with LTC and their unmet health needs. The current focus group study aims to explore the experiences and perceptions to SP interventions from the perspective of people with long-term conditions, link workers, healthcare providers and community-based services. Methods Six toeight participants will be recruited into three specific 60 to 90 minute focus groups relative to their role as a patient, link worker and community-based service. 8 to12 participants with a Health care provider and GP background will be interviewed individually online. The participants within these focus groups and semi-structured interviews will be invited to provide opinions on what factors they think are important to the successful implementation of a SP service from their respective stakeholder positions. The data will be recorded and exported to NVivo software for further analysis using Thematic Reflexive analysis methods. Coded categorical data will inform emerging themes from which a narrative summary will be consolidated and presented for dissemination. Conclusion The conclusions made from this study will help inform the next study, which will aim to develop a pilot SP service for patients with long-term musculoskeletal conditions as part of an overall larger project.