Long-term Nursing Home Care Research Articles

Care Trajectories of Veterans in the 12 Months After Hospitalization for Acute Ischemic Stroke.

Recovery after a stroke varies greatly between individuals and is reflected by wide variation in the use of institutional and home care services. This study sought to classify veterans according to their care trajectories in the 12 months after hospitalization for ischemic stroke. The sample consisted of 3811 veterans hospitalized for ischemic stroke in Veterans Health Administration facilities in 2007. Three outcomes--nursing home care, home care, and mortality--were modeled jointly >12 months using latent class growth analysis. Data on Veterans' care use and cost came from the Veterans Administration and Medicare. Covariates included stroke severity (National Institutes of Health Stroke Scale), functional status (functional independence measure score), age, marital status, chronic conditions, and prestroke ambulation. Five care trajectories were identified: 49% of Veterans had Rapid Recovery with little or no use of care; 15% had a Steady Recovery with initially high nursing home or home care that tapered off; 9% had Long-Term Home Care; 13% had Long-Term Nursing Home Care; and 14% had an Unstable trajectory with multiple transitions between long-term and acute care settings. Care use was greatest for individuals with more severe strokes, lower functioning at hospital discharge, and older age. Average annual costs were highest for individuals with the Long-Term Nursing Home trajectory ($63,082), closely followed by individuals with the Unstable trajectory ($58,720). Individual with the Rapid Recovery trajectory had the lowest costs ($9271). Care trajectories after stroke were associated with stroke severity and functional dependency and they had a dramatic impact on subsequent costs.

Social determinants of duration of last nursing home stay at the end of life in Switzerland: a retrospective cohort study.

BackgroundDue to demographic ageing and increasing life expectancy, a growing demand for long-term nursing home care can be expected. Stays in nursing homes appear to be more socially determined than hospital stays. We therefore looked at the impact of socio-demographic and health care variables on the length of the last nursing home stay.MethodsNationwide individual data from nursing homes and hospitals in Switzerland were linked with census and mortality records. Gender-specific negative binomial regression models were used to analyze N = 35,739 individuals with an admission age of at least 65 years and deceased in 2007 or 2008 in a nursing home.ResultsPreceding death, men spent on average 790 days and women 1250 days in the respective nursing home. Adjusted for preceding hospitalizations, care level, cause of death and multimorbidity, a low educational level, living alone or being tenant as well as a low care level at the admission time increased the risk for longer terminal stays. Conversely, a high educational level, being homeowner, being married as well as a high care level at the admission time decreased the risk for longer stays.DiscussionThe length of the last nursing home stay before death was not only dependent on health-related factors alone, but also substantially depended on socio-demographic determinants such as educational level, homeownership or marital status. The support of elderly people at the admission time of a presumably following nursing home stay should be improved and better evaluated in order to reduce unnecessary and undesired long terminal nursing home stays.ConclusionsHealth policy should aim at diminishing the role of situational, non-health-related factors in order to empower people to spend the last years before death according to individual needs and preferences.

Abstract W P296: Care Trajectories and Costs after Ischemic Stroke for Patients in the Veterans Health Administration

Background: Patients vary greatly in their use of care after hospitalization for stroke. We classified stroke patients according to their care trajectories and associated costs in the 12-month period after hospital discharge. Methods: We followed a cohort of 3,811 veterans for one year after hospitalization with ischemic stroke in Veterans Health Administration facilities in 2007. Three discharge outcomes -- nursing home care, home care, and mortality -- were modeled jointly with Latent Class Growth Analysis. VA and Medicare costs were obtained for use of institutional care (inpatient acute, rehabilitation facility, and nursing home) and home care (home health, other home care, and outpatient rehabilitation). Covariates included patient age, NIHSS stroke severity and FIM scores measured at hospital discharge. Results: Members of the cohort had one of five care trajectories: 49% had a Rapid Recovery with little or no use of care in the 12 months after discharge, 15% had a Gradual Recovery with initially high nursing or home care use that tapered off over time, 9% had consistent use of Long-Term Home Care (HC), 13% had consistent use of Long-Term Nursing Home Care (NH), and 14% had an Unstable trajectory with multiple transitions between long-term and acute care. Patients with Long-Term NH and Unstable trajectories had the highest average total costs (greater than $60,000 per person) and patients with the Rapid Recovery trajectory had the lowest cost (less than $11,000 per person). Medicare accounted for 23% of total costs. In a multinomial regression model, the likelihood of a Long-Term NH, Long-Term HC or an Unstable Trajectory was greatest for persons with more severe strokes (higher NIHSS score), more disability (lower FIM score), and age 65 or older. About half of the veterans received rehabilitation services. Most rehabilitation was delivered in the NH. There was no clear association between use of rehabilitation and subsequent care trajectory. Conclusions: Care trajectories were explained partly by veteran health and functional status. However, we need a better understanding of system factors shaping care trajectories, particularly access to and use of rehabilitation services.

The Prevalence of Alzheimer’s Disease and Dementia in Alzheimer’s Disease in Patients of Long-Term Nursing Home Care in the Podlaskie Province in Poland

The prevalence of Alzheimer’s disease and dementia in Alzheimer’s disease according to the International Statistical Classification of Diseases and Related Health Problems ICD-10 in patients of long-term nursing home care in the Podlaskie province is not yet known. The aim of the study was the socio-demographic assessment of the long-term nursing home care patients with diagnosed Alzheimer’s disease and socio-demographic assessment of the long-term nursing home care patients with dementia in Alzheimer’s disease. Data concerning all 7637 patients who received long- term nursing home care benefits in the years from 2008 to 2013 in the Podlaskie province were investigated. Alzheimer’s disease was diagnosed in 2.972% of patients at the average age of 79.82 years (±8.05). The disease was diagnosed more frequently (78.4%) and earlier in women (from 44 years of age). Dementia in Alzheimer’s disease was diagnosed in 210 patients (2.749%). The mean age of patients with Alzheimer’s dementia was 81.72 years (±7.73). Stupor in patients under 65 years more frequently affected women. Research confirms the impact of Alzheimer’s disease and dementia in Alzheimer’s disease on daily activity performance. Studies suggest that the high rate of Alzheimer’s disease and dementia in Alzheimer’s disease is due to ethnic and national differences associated with learning at home and in schools in the Podlaskie province.

The Herth Hope Index—A Psychometric Study Among Cognitively Intact Nursing Home Patients

Hope is seen as the act by which the temptation of despair is actively overcome and has thus been interpreted as an inner strength and an available resource for living in the present. An understanding of hope and its meaning in the lives of institutionalized older adults may aid in developing interventions to enhance hope and well-being in the nursing home setting. This study aimed to investigate the psychometric properties of the Norwegian version of the Herth Hope Index among cognitively intact nursing home patients. Cross-sectional data was obtained in 2008 and 2009 from 202 of 250 patients who met the inclusion criteria in 44 different nursing homes. Exploratory factor analysis revealed 3 internal consistent dimensions of hope, explaining 51.2% of the variance. The 1-factor, 2-factor, and the originally 3-factor solutions of the Herth Hope Index were tested by means of confirmatory factor analysis. A 2-factor construct comprising 11 items came out with the best model fit. The Herth Hope Index was found to be a reliable and valid instrument for assessing hope in nursing home patients. The 2-factor structure was psychometrically superior the original 3-factor construct of hope in this particular sample. The Herth Hope Index might be used to assess hope and changes in the hope process during long-term nursing home care. An enhanced understanding of hope in this population might contribute to increased quality of nursing home care.

Medical Conditions of Nursing Home Admissions

BackgroundAs long-term nursing home care is likely to increase with the aging of the population, identifying chronic medical conditions is of particular interest. Although need factors have a strong impact on nursing home (NH) admission, the diseases causing these functional disabilities are lacking or unclear in the residents' file. We investigated the medical reason (primary diagnosis) of a nursing home admission with respect to the underlying disease.MethodsThis study is based on two independent, descriptive and comparative studies in Belgium and was conducted at two time points (1993 and 2005) to explore the evolution over twelve years. Data from the subjects were extracted from the resident's file; additional information was requested from the general practitioner, nursing home physician or the head nurse in a face-to-face interview. In 1993 we examined 1332 residents from 19 institutions, and in 2005 691 residents from 7 institutions. The diseases at the time of admission were mapped by means of the International Classification of Diseases - 9th edition (ICD-9). Longitudinal changes were assessed and compared by a chi-square test.ResultsThe main chronic medical conditions associated with NH admission were dementia and stroke. Mental disorders represent 48% of all admissions, somatic disorders 43% and social/emotional problems 8%. Of the somatic disorders most frequently are mentioned diseases of the circulatory system (35%) [2/3 sequels of stroke and 1/5 heart failure], followed by diseases of the nervous system (15%) [mainly Parkinson's disease] and the musculoskeletal system (14%) [mainly osteoarthritis]. The most striking evolution from 1993 to 2005 consisted in complicated diabetes mellitus (from 4.3 to 11.4%; p < 0.0001) especially with amputations and blindness. Symptoms (functional limitations without specific disease) like dizziness, impaired vision and frailty are of relevance as an indicator of admission.ConclusionDiseases like stroke, diabetes and mobility problems are only important for institutionalisation if they cause functional disability. Diabetes related complications as cause of admission increased almost three-fold between 1993 and 2005.

Annual Expenditures for Nursing Home Care

Long-term nursing home care is primarily funded by out-of-pocket payments and public Medicaid programs. Few studies have explored price growth in nursing home care, particularly trends in the real cost of a year spent in a nursing home. To evaluate changes in private and public prices for annual nursing home care from 1977 to 2004, and to compare nursing home price growth to overall price growth and growth in the price of medical care. We estimated annual private prices for nursing home care between 1977 and 2004 using data from the National Nursing Home Survey. We compared private nursing home price growth to public prices obtained from surveys of state Medicaid offices, and evaluated the Bureau of Labor Statistics Consumer Price Indexes to compare prices for nursing homes, medical care, and general goods and services over time. Annual private pay nursing homes prices grew by 7.5% annually from $8645 in 1977 to $60,249 in 2004. Medicaid prices grew by 6.7% annually from $9491 in 1979 to $48,056 in 2004. Annual price growth for private pay nursing home care outpaced medical care and other goods and services (7.5% vs. 6.6% and 4.4%, respectively) between 1977 and 2004. The recent rapid growth in nursing home prices is likely to persist, because of an aging population and greater disability among the near-elderly. The result will place increasing financial pressure on Medicaid programs. Better data on nursing prices are critical for policy-makers and researchers.

CVA-patiënten die aangewezen zijn op langdurige verpleeghuiszorg.

Many patients who suffer from an acute stroke, will need long-term nursing home care. We are poorly informed about the demographic and clinical characteristics and about the care problems and received care of these patients. This study aims to provide a first description of these characteristics in this group of patients.Data on demographic and health-related characteristics, social participation and received care were collected with the Minimum Data Set of the Resident Assessment Instrument, from january 2004-march 2007, in patients who needed long-term nursing home care. Data were collected in eight nursing homes at admission and six months after admission.Many patients were functionally impaired, suffered from depressive symptoms and pain, and were cognitively impaired. In addition, decisional capacity was frequently diminished. The majority of patients were residing at somatic wards, even when severe cognitive impairment was present, such as dementia. Several forms of restraints were frequently used, also at somatic wards. About 40% of the patients, mostly residing at somatic wards, received paramedical treatment. Social engagement was low and was correlated with functional impairment.Stroke patients who need long-term nursing home care suffer from problems in several domains. The high prevalence of cognitive impairment in stroke patients residing at somatic wards, combined with the ample use of restraints on these wards, raises questions about the appropriateness of the currently delivered care to these patients, considering the problems they have.

Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis

SummaryBackgroundIn old age, reduction in physical function leads to loss of independence, the need for hospital and long-term nursing-home care, and premature death. We did a systematic review to assess the effectiveness of community-based complex interventions in preservation of physical function and independence in elderly people.MethodsWe searched systematically for randomised controlled trials assessing community-based multifactorial interventions in elderly people (mean age at least 65 years) living at home with at least 6 months of follow-up. Outcomes studied were living at home, death, nursing-home and hospital admissions, falls, and physical function. We did a meta-analysis of the extracted data.FindingsWe identified 89 trials including 97 984 people. Interventions reduced the risk of not living at home (relative risk [RR] 0·95, 95% CI 0·93–0·97). Interventions reduced nursing-home admissions (0·87, 0·83–0·90), but not death (1·00, 0·97–1·02). Risk of hospital admissions (0·94, 0·91–0·97) and falls (0·90, 0·86–0·95) were reduced, and physical function (standardised mean difference −0·08, −0·11 to −0·06) was better in the intervention groups than in other groups. Benefit for any specific type or intensity of intervention was not noted. In populations with increased death rates, interventions were associated with reduced nursing-home admission. Benefit in trials was particularly evident in studies started before 1993.InterpretationComplex interventions can help elderly people to live safely and independently, and could be tailored to meet individuals' needs and preferences.

“JDC-ESHEL,” a unique non-governmental organization dedicated to the elderly in Israel

“JDC-ESHEL,” a non-governmental organization (NGO), has over the past 35 years been involved in the planning and development of services for the elderly in Israel. This organization functions under the auspices of the Joint Distribution Committee (JDC), an American based NGO which provides relief, rescue and reconstruction services to Jewish and non-Jewish clients around the world. Under the roof of the relevant government ministries, JDC-ESHEL brings together prominent stakeholders and professionals involved in the care of Israel's older citizens in order to plan and initiate pilot projects relevant to the elderly. Through an explicit consultative process, this NGO has developed services both in the community as well as in the institutional sectors, helping in this way to keep the rates of both acute and long-term nursing home care in Israel down to manageable levels. JDC-ESHEL offers an instructive example of how a nationally based NGO can play a major role in the planning and development of relevant services for the elderly, via the leverage produced through its relatively modest budget. In this way it provides a multiplier effect throughout the entire health and social service sectors.

Consequences of Preventing Delirium in Hospitalized Older Adults on Nursing Home Costs

To determine whether costs of long-term nursing home (NH) care for patients who received a multicomponent targeted intervention (MTI) to prevent delirium while hospitalized were less than for those who did not receive the intervention. Longitudinal follow-up from a randomized trial. Posthospital discharge settings: community-based care and NHs. Eight hundred one hospitalized patients aged 70 and older. Patients were followed for 1 year after discharge, and measures of NH service use and costs were constructed. Total long-term NH costs were estimated using a two-part regression model and compared across intervention and control groups. Of the 400 patients in the intervention group and 401 patients in the matched control group, 153 (38%) and 148 (37%), respectively, were admitted to a NH during the year, and 54 (13%) and 51 (13%), respectively, were long-term NH patients. The MTI had no effect on the likelihood of receiving long-term NH care, but of patients receiving long-term NH care, those in the MTI group had significantly lower total costs, shorter length of stay and lower cost per survival day. Adjusted total costs were $50,881 per long-term NH patient in the MTI group and $60,327 in the control group, a savings of 15.7% (P=.01). Active methods to prevent delirium are associated with a 15.7% decrease in long-term NH costs. Shorter length of stay of patients receiving long-term NH services was the primary source of these savings.

Syringe Feeding in Long-Term Care

Syringe Feeding in Long-Term Care

Discrimination against self-funding residents in long-term residential care in England

This paper reports the findings of research funded by The Nuffield Foundation on older people paying the full cost of their long-term residential or nursing home care in England. The research had three stages; a national postal survey directed at the senior finance officer in social services departments, follow-up telephone interviews with a sample of them, and interviews in five case study areas. Those interviewed included social services staff (including a legal adviser), care home providers, self-funding residents and relatives. These self-funding residents were commonly relatively physically independent on admission to the care home. Despite central government directives that needs assessments should be available regardless of a person's means, it is a common policy to encourage older people in this situation to admit themselves directly to care homes without a needs assessment. Wide variation was found in local authority practice in respect to being prepared to make a contract with a care-home provider for older people able to meet the full costs of care.

Views of job satisfaction and dissatisfaction in Australian long-term care.

The existing job satisfaction literature has tended towards an overemphasis on job satisfaction instruments. In the study reported here the views of 27 nurses and assistants-in-nursing, collected through focus group interviews, were examined to determine the factors that contribute to workplace satisfaction and dissatisfaction in long-term care of older people. Content analysis of focus group interview data revealed that job satisfaction was related to workplace flexibility, residents, working within a team environment and dedication to the service of optimal resident care. Dissatisfaction was linked to working with unskilled or inappropriately trained staff, laborious tasks such as documentation, staffing levels, tensions within role expectations and the increasing need to be available for overtime. In spite of different role expectations, long-term nursing home care is reported to be a very satisfying area in which to work. However, care managers need to put in place strategies for building improved job satisfaction and workplace incentives to encourage graduates to consider long-term care opportunities. Limitations of the study include the small number of participants, bias towards one organization and lack of generalizability of the results. However, the findings confirm many earlier job satisfaction studies and further support the need to consider these issues in relation to recruitment and retention in long-term care.

Nosocomial transmission of influenza.

Influenza is a common nosocomial infection. Serious outbreaks occur typically in elderly long-term patients, but have also been reported in renal, transplant and oncology units, neonatal intensive care and paediatrics. It is likely that staff-patient cross-infection is common. Prompt diagnosis of an outbreak lies at the heart of an effective influenza control programme. This requires effective virological surveillance. There are a variety of strategies that can help to prevent spread of influenza in health care settings. Basic infection control should include isolating infected residents, restricting circulation of nursing staff between patients, and restriction of visitors. Annual influenza immunization should be offered to elderly patients, subjects with chronic disease, and those in long-term residential or nursing home care. Vaccination of health care workers has been shown to be effective in protecting elderly patients in long-term care. Use of oral amantadine or rimantadine is an additional possible strategy for prophylaxis or treatment during an outbreak.

The current cost of heart failure to the National Health Service in the UK.

We have recently shown that heart failure admission rates continue to increase in the UK -- particularly in older age groups. As hospital activity represents the major cost component of health care expenditure related to heart failure, this study evaluated the current cost of this syndrome to the National Health Service (NHS) in the UK. We applied contemporary estimates of health care activity associated with heart failure to the whole UK population on an age and sex-specific basis to calculate its cost to the NHS for the year 1995. Direct components of health care included in these estimates were hospital admissions associated with a principal diagnosis of heart failure, associated outpatient consultations, general practice consultations and prescribed drug therapy. We also calculated the cost of nursing-home care following a primary heart failure admission and the cost of hospitalisations associated with a secondary diagnosis of heart failure. Adjusting for probable increases in hospital activity and the progressive ageing of the UK population, we have also projected the cost of heart failure to the NHS for the year 2000. We estimated that there were 988000 individuals requiring treatment for heart failure in the UK during 1995. The 'direct' cost of health care for these patients was estimated to be pound 716 million, or 1.83% of total NHS expenditure. Hospitalisations and drug prescriptions accounted for 69 and 18% of this expenditure, respectively. The additional costs associated with long-term nursing home care and secondary heart failure admissions accounted for a further pound 751 million (2.0% of total NHS expenditure). By the year 2000, we estimated that the combined total direct cost of heart failure would have risen to pound 905 million -- equivalent to 1.91% of total NHS expenditure. Using well-validated sets of data, these findings re-confirm the importance of heart failure as a major public health problem in the UK. The annual direct cost of heart failure to the NHS in 2000 is likely to be of the order of 1.9% of total expenditure -- the predominant cost component being hospitalisation.

Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture

Osteoporosis is a major health problem among older adults, and it often results in substantial morbidity and disability. Hip fractures are responsible for most of the osteoporosis-related health care demands, with more than half a million fractures in the United States each year. It is estimated that by the ninth decade of life, 1 in every 3 women and 1 in every 6 men will have had a hip fracture ( 1 Birge S.J. Morrow-Howell N. Proctor E.K. Hip fracture. Clin Geriatr Med. 1994; 10: 589-609 PubMed Google Scholar ). The short-term mortality from a hip fracture ranges from 10% to 20% ( 2 Cumming S.R. Black D.M. Rubin S.M. Lifetime risks of hip, collar or vertebral fracture and coronary artery disease among white postmenopausal women. Arch Intern Med. 1989; 149: 2445-2448 Crossref PubMed Google Scholar ). Among survivors, half require assistance walking, and one quarter require long-term nursing home care ( 3 Beatriz J.E. Perry III, H.M. Age-related osteoporosis. Clin Geriatr Med. 1994; 10: 575-587 PubMed Google Scholar ). The health care expenditure attributable to osteoporotic fractures in the United States in 1995 was estimated at $13.8 billion, 28% of which was spent for nursing home care ( 4 Ray N.F. Chan J.K. Thamer M. Mellton L.J. Medical expenditure for the treatment of osteoporotic fractures in the United States in 1995 report from the National Osteoporotic Foundation. J Bone Miner Res. 1997; 12: 24-35 Crossref PubMed Scopus (1160) Google Scholar ).

United States of America

To call the way health care is organised and delivered in the United States a system is charitable, at best. The arrangements under which most Americans today receive medical services are a patchwork based more on historical accidents and political compromises than on any organised thought process. That the finest cutting-edge scientific and medical establishment in the world can have arisen from such chaos strains credulity hardly less than the rise of life itself from the primordial ooze. For example, a majority of Americans—though the percentage is shrinking all the time—receive health insurance coverage through their employers. In 1994, the last year for which statistics are available, 64% of Americans under age 65 (more on those over that age in a moment) enjoyed health insurance financed in full or in part by the employer of one of the family members. Yet employer-provided insurance is essentially a quirk of history—it began during World War II when companies were prohibited from raising wages to attract workers from a pool shrunken by the armed forces. Instead, companies began offering fringe benefits, and hospitalisation insurance became a popular job perk. But as more and more members of the workforce were receiving health insurance coverage, enabling them to pay for the increasing number—and increasing cost—of medical miracles, those in retirement were being left further and further behind. In 1965 Congress sought to remedy that by creating Medicare, the federal health programme for the elderly (and, since 1972, some disabled individuals). In 1995 Medicare provided health coverage to 37 million people—one of every seven Americans (figure 1). Medicare remains yet another conundrum in the US health care system. Although highly popular with its beneficiaries, it offers an increasingly meagre package of benefits. For instance, it provides virtually no coverage for outpatient prescription drugs, a major expense for most elderly individuals, pays for few preventive services (screening mammography benefits were added only in 1991), and requires large amounts of cost-sharing from a population in which three-fourths have annual incomes of less than $25 000. For that reason, two-thirds of beneficiaries purchase private Medicare supplemental insurance policies, known as Medigap. Medicare represents a conundrum in another way. While the US health care system is primarily private, the federal government, through Medicare, actually exercises substantial influence by virtue of the dollars it pays to health care providers. For example, Medicare pays nearly a third of the nation’s hospital bill and nearly a quarter of physician fees. Medicare also pays for nearly half the costs of the nation’s bill for graduate medical education. Taxpayers also fund health care services to the poorest of the poor, through the joint state-federal Medicaid programme. Largely an adjunct to cash-assistance programmes, in 1995 Medicaid covered 37 million Americans, half of them children. Medicaid also covers 4 million senior citizens, most of whom are also eligible for Medicare, because Medicaid pays for long-term nursing home care, which Medicare does not cover. Medicaid’s growth in recent years—mostly the result of congressional Democrats’ efforts to expand eligibility beyond the traditional welfare population—have helped keep the percentage of Americans without any health coverage from rising even further. Without Medicaid expansions, an estimated 9 million more Americans would currently lack coverage for health expenses. Still, some 17% of Americans under age 65—about 40 million people—have no health insurance at all. And ironically, in a nation where the public believes that people

Long-Term Nursing Home Care in The Netherlands

RÉSUMÉLa population des Pays-Bas était l'une des plus jeunes des pays de l'Europe de l'Ouest dans les années 60 et 70. La proportion de personnes âgées dans la population n'augmentera de façon sensible qu'après l'an 2010. Malgré ce vieillissement relativement tardif de la population, le gouvernement hollandais a très tôt élaboré une politique du vieillissement. Une attention toute particulière a été accordée, au cours des années 60 et 70, aux soins institutionnels prodigués aux personnes âgées. Cette politique a amené une grande partie des personnes âgées à vivre en institution. En 1982, 3 pour cent des personnes de 65 ans et plus habitaient des centres d'hébergement et 9 pour cent des résidences pour personnes âgées. Ces établissements de santé sont gérés comme des organismes à but non lucratif. Ils sont largement financés par des impôts directs et indirects. Leur clientèle se compose avant tout de personnes àgées dites fragiles. Toutefois, les résidences pour personnes âgées ont été perçues au départ comme un mode de logement pour les âinés. Les coûts liés aux soins institutionnels ont considérablement augmenté dans les années 60 et 70. Le gouvernement a tenté de juguler les coûts en instaurant des procédures administratives comme des contraintes d'admission dans les résidences pour personnes âgées ou l'établissement de critères de planification rigoureux. Ces mesures ne se sont pas révélées très efficaces jusqu'à la fin des années 80. Par contre, la promotion des soins communautaires de longue durée semble contribuer favorablement à la compression des coûts.

Adding long-term care to Medicare: The Social HMO Experience.

The rancor accompanying the repeal of most of the 1988 Medicare Catastrophic Act reflects both the national need to improve health and long-term care benefits for the elderly and the political obstacles to finding new sources of financing for such benefits. Neither the need nor the obstacles will go away, but policymakers are now likely to look for lower-cost, efficient, and privately funded alternatives. The authors have developed and tested one such approach: the Social Health Maintenance Organization (SHMO). Operating since 1985, the SHMO model integrates community-based, long-term care services into the managed, prepaid HMO design. The four test sites are adding long-term care to Medicare at no extra cost to the government and only modest premiums for the 17,000 current members. Although the benefits offer limited protection for long-term nursing home care, they do cover long-term care in community settings, where people tend to prefer to stay. Also, integration of the acute and long-term care systems improves the ability to respond to the medical needs of frail members, who also have high acute-care use. The SHMO's model of front-end, community-oriented, long-term care benefits integrated with Medicare appears to be a practical, affordable, and clinically appropriate way to address the rising concern with the lack of coverage and services for long-term care.