Robert J. Buchanan

The Social Environment and Medicaid Expenditures: Factors Influencing the Level of State Medicaid Spending

including a callfor greater state-level management. The state Medicaid programs, financed jointly with federal and state funds, were created in 1965 to provide health coverage to the poor. One of the largest domestic programs, combined federal and state expenditures for Medicaid coverage of health care services are projected to exceed

Informal care giving to more disabled people with multiple sclerosis.

66 billion during 1991.1 During fiscal year 1988, Medicaid expenditures approached

Analyses of nursing home residents in hospice care using the Minimum Data Set

49 billion while covering the health services of 22.9 million beneficiaries.2

End-of-Life Care in Nursing Homes: Residents in Hospice Compared to Other End-Stage Residents

Purpose. About 30% of the people with multiple sclerosis (MS) require some form of home care assistance and 80% of that assistance is provided by informal or unpaid care givers. This study focusses on the care givers for 530 more disabled people with MS, with the objective of learning more about informal care giving to people with greater dependency and need for assistance. Method. The data presented in this study were collected in a national survey of 530 people who provided informal care to more disabled people with MS. Results. Almost half of these care givers reported that they provided more than 20 h of care per week to the person with MS, with more than 9 in 10 shopping for groceries, doing indoor housework, preparing meals or providing transportation for the person with MS. More than 4 in 10 employed care givers reduced the amount of time worked in the previous 12 months because of their care giving responsibilities. Although more than half of the MS care givers in our study reported that care giving was demanding, time consuming or challenging, about 90% of these MS care givers were happy that they could help. About two in three of these MS care givers found that care giving was rewarding, with more than 8 in 10 proud of the care they provided. Conclusions. More than a quarter of the informal care givers to people with MS thought they would benefit from treatment or counselling provided by mental health professionals. Not only it is necessary to provide access to mental health services for people with MS, but it is also important to assure that their informal care givers also have access to appropriate mental health care, given the scope of their care giving responsibilities.

Profiles of nursing home residents with multiple sclerosis using the minimum data set

Objective: To present comprehensive profiles of residents in hospice care at admission to the nursing home using the Minimum Data Set (MDS). Design and Setting: We analysed 40,622 MDS admission assessments for nursing home residents in hospice care. The MDS contains resident-focused data on pain, cognitive patterns, physical function, disease diagnoses, medications, nutrition, and specific treatments received. Results: About four in five recently admitted hospice residents had ‘do not resuscitate’ orders and only 27% had a living will. Over 70% of recently admitted hospice residents experienced pain, with almost one half experiencing daily pain. Over one half of those hospice residents in pain experienced moderate pain and almost one third experienced horrible or excruciating pain. About 57% of recently admitted hospice patients had cancer, 21% had congestive heart failure, 20% had emphysema/chronic obstructive pulmonary disease, and 18% had depression. About one in two recently admitted hospice residents exhibited at least moderate impairment in cognitive function. Conclusions: There is a need to improve pain management, advanced directives, and mental health services for residents dying in nursing homes.

Burden among male caregivers assisting people with multiple sclerosis.

OBJECTIVE To compare residents in hospice care at admission to the nursing facility to end stage residents not in hospice at admission. DESIGN AND METHODS We analyzed 18,211 admission assessments recorded in the Minimum Data Set (MDS) during the year 2000 throughout the United States for residents classified as having an end-stage disease (6 or fewer months to live). Fifty-nine percent (n = 10,656) of these residents were in hospice care at the time of their admission assessment. We used these MDS admission assessments to compare residents in hospice care to other end-stage residents not in hospice for demographic characteristics, health status, and treatments. RESULTS Hospice residents at admission were significantly more likely to be female, older, white, and widowed than other end-stage residents at admission. There were significant differences between hospice residents and other residents at end stage in the use of advanced directives at admission. Hospice residents at admission experienced significantly more frequent and more intense pain than other end-stage residents at admission, while these hospice residents also showed greater impairment in cognitive ability and physical function. While cancer was the most common disease among these end-stage residents, it was significantly more prevalent among hospice residents. IMPLICATIONS Many end-stage residents may not be receiving adequate palliative care in nursing facilities; further study of this is warranted. The MDS should be revised to record minimum standards for palliative care with or without the use of hospice to improve end-of life care in nursing facilities.

Analyses of gender differences in profiles of nursing home residents with Alzheimer's disease.

This paper profiles nursing home residents with multiple sclerosis (MS) at the time of admission, including sociodemographic characteristics, health status measures, and treatments received. Admission assessments from the Minimum Data Set are used to create these profiles of residents with MS. There are 9013 admission assessments in the MDS for residents with MS between June 22, 1998 and January 17, 2000 analyzed for this study. Residents with MS are distinctly younger at admission than most nursing home residents, averaging 57.98 years of age. Recently admitted residents with MS are more physically dependent than other nursing home residents and tend to have limited range of motion and loss of voluntary movement. About one in three newly admitted residents with MS had some degree of impaired cognitive function. Over one third of residents with MS were depressed at admission, yet only 11.7% of recently admitted residents with MS were evaluated by a licensed mental health specialist. This prompts concern about the psychosocial well-being of MS residents in nursing homes.

Perceptions of informal care givers: health and support services provided to people with multiple sclerosis.

BACKGROUND Caregiver burden is a multidimensional response to many factors associated with providing assistance to people with multiple sclerosis (MS), including physical, psychological, emotional, and social stressors. OBJECTIVE The aim of this analysis was to identify the characteristics of male informal caregivers, the assistance provided, and the people receiving assistance who were associated with the burden of care. METHODS Data were collected from a national survey (which included the Mental Component Summary of the SF-8 Health Survey) of informal caregivers and analyzed using an ordered logistic regression model to identify characteristics associated with burden among male informal caregivers. RESULTS Greater burden among male caregivers was associated with significantly greater hours per week providing assistance (P = 0.009) and significantly greater restriction on the caregivers ability to perform daily activities (P < 0.001) due to assisting the person with MS. We found a strong association between the perception of burden and the mental health status of the male caregiver (P < 0.001). CONCLUSIONS Our findings highlight the strong association of caregiver burden and the Mental Component Summary of the SF-8. Reducing burden may improve the mental health of informal caregivers. Health professionals treating either male caregivers or people with MS should be sensitive to the impact that providing assistance has on the mental health of informal caregivers.

Health-related quality of life among informal caregivers assisting people with multiple sclerosis.

BACKGROUND Alzheimers disease (AD), a progressive, neurodegenerative disorder characterized by memory loss, language deterioration, impairment of visuospatial skills, poor judgment, and indifference, but preserved motor function, is the most common type of dementia, accounting for two thirds or more of all cases of dementia. The identification of differences between men and women with AD might present opportunities to improve the quality of AD-related care provided by nursing facilities, as well as lead to additional analyses of nursing home residents with AD. OBJECTIVE The objectives of this study were to gain additional insight into gender differences in nursing home residents with AD in the United States, and to provide a better understanding of their health status and the care they receive in nursing facilities. METHODS All admission assessments recorded in the Minimum Data Set (MDS) throughout the United States during 2000 were analyzed. P values for all significant differences were <0.001. RESULTS A total of 49,607 residents with a diagnosis of AD (67.9% women) were identified. Female residents with AD were more likely to be older and widowed, whereas male residents with AD were more likely to be married. We found minimal gender differences in cognitive impairment among these residents with AD, although women were more likely to understand and be understood by others. Male residents with AD were more likely to exhibit behavioral symptoms, whereas female residents with AD tended to be more physically impaired and dependent on others for activities of daily living. Significant differences in comorbidities were found between the sexes, with greater proportions of male residents with AD having cardiac-related conditions, stroke, cancer, and other life-threatening chronic conditions. Male residents with AD were more likely to receive care in AD special-care units; daily antipsychotic medications; and intervention programs for mood, behavior, and cognitive loss than female residents with AD. CONCLUSIONS In this study of nursing home residents identified using the MDS, key differences were found between male and female residents with AD, including age; cognitive and communicative abilities; and mental health, mood, and behavioral patterns.

Analyses of Nursing Home Residents With Cancer at Admission

Purpose. About 30% of people with multiple sclerosis (MS) need some form of home care assistance, with 80% of that assistance provided by informal or unpaid care givers. This study focuses on the care givers to 530 more disabled people with MS, with the objective to learn more about informal care giving to people with greater dependency and need for assistance. Method. The data presented in this study were collected in a national survey of 530 informal care givers to people with MS who have greater levels of physical dependency. Results. About 70% of informal care givers responded that assisting the person with MS perform daily activities or personal care took up the largest amount of their care giving time. Care givers also reported a range of home and community-based services that would make care giving easier or improve the care provided. However, informal care givers generally reported low satisfaction with health insurance coverage of these services, especially coverage by health maintenance organizations and other managed care plans. Conclusions. Lack of health insurance coverage of needed home and community-based services can reduce the quality of informal care provided, as well as increase the burden of informal care giving.