Walter Leutz

Reflections on Integrating Medical and Social Care: Five Laws Revisited

This paper reviews, rethinks, expands and applies the author’s ‘laws’ of integration, which were first published six years ago. This approach both introduces the laws to readers who don’t know them, and tests their utility for those who do. In retrospect, real-world integration efforts mix and match the original components of linkage, co-ordination and full integration. But the message remains to work at all levels, keep it simple, make finances supportive and empower social care.

Community-based care and risk of nursing home placement

Objective. To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly. Research Design. The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a “natural experiment.” Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999. To adjust for site effects and secular trends, we also followed age- and gender-matched Medicare-Tax Equity and Fiscal Responsibility Act (TEFRA) cohorts, enrolled in the same HMOs but not in the Social HMOs. Subjects. All enrollees in the Social HMO for at least 4 months in 1993 and an age-gender matched sample of Medicare–TEFRA enrollees. To be included, individuals had to be alive and have a period out of an institution after January 1, 1995 (total n = 18,143). Measures. The primary data sources were the electronic databases at HP and KPNW. The main outcomes were long-term nursing home placement (90+ days) or mortality. Covariates were age, gender, a comorbidity index, and geographic site effect. Results. Adjusting for variations in the 2 sites, we found no difference in probability of mortality between the 2 cohorts, but approximately a 40% increase in long-term institutional placement associated with the termination of the Social HMO at HealthPartners (odds ratio, 1.43; 95% confidence interval, 1.15–1.79). Conclusions. The Social HMO appears to help at-risk elderly postpone long-term nursing home placement.

Family well-being in a participant-directed autism waiver program: the role of relational coordination

BACKGROUND Massachusetts is one of a very limited number of states exclusively employing participant-direction to deliver autism waiver services to children. A crucial element of this waiver program is the work conducted by the states Department of Developmental Services (DDS) staff and state-approved providers with waiver families to facilitate the implementation of the participant-direction model. Our study investigates the effect of the collaboration between state providers and family caregivers on family well-being. METHODS We conducted a survey of 74 families who have been utilising waiver services for at least 6 months. Participants were asked to rate the coordination with providers as well as to report on parenting stress and impact of waiver services on family functioning. Data from in-home child and family assessments conducted by the state were also abstracted from program records. RESULTS After controlling for a host of variables hypothesised to affect the outcomes of interest, we found that the familys view of how well they coordinated with formal providers is significantly associated all of the outcomes. Families who reported greater coordination with state providers experienced lower parenting stress and reported a more positive impact on family functioning. Child externalising behavioural problems and caregivers health rating also contributed to parenting stress and family functioning. CONCLUSIONS Our findings highlight the importance of establishing a collaborative partnership with waiver families in promoting family well-being. These results suggest that training and/or resources that foster team building and communication can positively impact family functioning among families with young children with autism.

“In the Driver’s Seat”: Parent Perceptions of Choice in a Participant-Directed Medicaid Waiver Program for Young Children with Autism

This study investigated families’ experience of choice within a participant-directed Medicaid waiver program for young children with autism. Fourteen parents or grandparents participated in in-depth interviews about their experience of choosing personnel, directing in-home services, and managing the

Caregiver Education and Support: Results of a Multi-Site Pilot in an HMO

25,000 annual allocation. Key findings included families’ preference to hire providers with whom they have a prior relationship, parent empowerment and differences of opinion about parents as teachers. Professionals implementing participant directed service models could benefit from understanding the strong value parents’ placed on the personalities and interpersonal skills of providers. Parents’ descriptions of directing rather than merely accepting autism services revealed increased confidence in their ability to choose and manage the multiple components of their children’s HCBS autism waiver program.

Medicare managed care and frail elders: lessons from social HMOs.

ABSTRACT Caregiver workshops were offered to members by a group practice HMO as part of a larger demonstration of adding community care to HMO services. Of 1,200 members indicating interest at four sites, 532 participated in workshops and 320 completed pre- and post-questionnaires on effectiveness. Analyses showed improvements in caregiving preparedness and reductions in sadness and depression. Engagement in the workshops (completing 3 or more sessions) and improvements were more likely for individuals with more independent lives and social capital. Alternative helping strategies are recommended for caregivers who are less likely to engage in classes due to burden or lack of respite or transportation.

Met Needs, Unmet Needs, and Satisfaction Among Social HMO Members

After 20 years of operations, the Social HMO demonstration of integrated acute and long-term care is scheduled to end on December 31, 2004. While a new disability adjustment to the Medicare payment system promises to provide the financial underpinning for continuing to serve the 113,000 beneficiaries now enrolled at four sites, a broader regulatory structure as an alternative to current waivers is also needed. The regulations could also accommodate other frail elderly programs, which serve nursing home residents and beneficiaries of both Medicare and Medicaid. The relevance of Social HMOs—the largest and most broadly targeted of frail elderly programs—is reviewed herein, particularly regarding marketing, selectivity, reimbursement, and special frail elderly benefits and geriatric services.

Kaiser Permanente's manifesto 2005 demonstration: the promises and limits of devolution.

Abstract This article reports on a survey of 800 members of four Social HMO demonstration sites, who were receiving home-based, community-based, and short-term institutional services under the demonstrations expanded community care benefits. The survey asked whether members needed help in 11 areas, whether they received help in each area from an informal caregiver, whether they wanted more help from the Social HMO, and whether help provided by both was adequate. Satisfaction with the program and with service coordination was also assessed. The adequacy of informal care differed by problem area, as did the help desired from the Social HMO and its responsiveness. Members were less satisfied when they had weaker informal care, were African American, and when they received inadequate help from the plan with ADLs, transportation, medical access, and managing money. Members were more satisfied when they were professionals, home owners, knew their service coordinators name (or how to contact her), and received help with their problems. The findings point to the importance of clarifying divisions of labor with informal caregivers, as well as possible expansions in responsibilities for service coordinators and benefits beyond traditional boundaries.

Five Laws for Integrating Medical and Social Services: Lessons from the United States and the United Kingdom

Summary In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home-and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on “unprofitable” populations, for example, those who are chronically ill, poor, and/or disabled.