William G. Weissert

Predicting Elderly People’s Risk for Nursing Home Placement, Hospitalization, Functional Impairment, and Mortality: A Synthesis:

Long-term care resources would be allocated more cost-effectively if care planning and medical/functional eligibility decisions were grounded more firmly in extant evidence regarding the risk of nursing home placement, hospitalization, functional impairment, and mortality. This article synthesizes the studies that longitudinally assess the predictors of each of these outcomes for the 65 and older population in the United States. A database was assembled containing 167 multivariate analyses abstracted from 78 journal articles published between 1985 and 1998. Findings show that 22 risk factors consistently predict two or more outcomes, including three that predict all four: worse performance on physical function measures not based on activities of daily living, greater illness severity, and prior hospital use. Findings should help prioritize variable selection choices of those setting eligibility criteria, allocating care resources, and doing descriptive studies. Gaps are shown to exist in the understanding of outcome effects of facility, market, policy, and other system attributes.

Effects and Costs of Day-Care Services for the Chronically Ill A Randomized Experiment

Two long-term care settings not now covered by Medicare—adult day care and homemaker services—were studied in a randomized experiment to test the effects on patient outcomes and costs of using these new services. This article reports findings for day care. Patients’ physical, psychosocial and health functions were assessed quarterly, and their Medicare bill files were obtained. Medicaid data were obtained on most patients, but few used many Medicaidcovered long-term care services. Multistage analysis was performed to mitigate effects of departures from the randomized design. Day-care patients showed no benefits in physical functioning ability at the end of the study, compared with the control group. Institutionalization in skilled nursing facilities was lower for the experimental group than the control group, but factors other than the treatment variable appeared to explain most of the variance. There was a possibility that life was extended for some day-care patients. The new services averaged

Determinants of Nursing Home Discharge Status

52 per day or

Titrating Versus Targeting Home Care Services to Frail Elderly Clients An Application of Agency Theory and Cost-Benefit Analysis to Home Care Policy

3,235 per year. When costs for existing Medicare services used were added, the yearly cost of the experimental group was

Working Group Recommendations: Measuring Outcomes of Care in Geriatric Evaluation and Management Units

6,501, compared with

Regression-adjusted small area estimates of functional dependency in the noninstitutionalized American population age 65 and over.

3,809 for the control group—an increase of

Strategies for integrating Medicare and Medicaid: design features and incentives.

2,692 or 71 per cent.

Incidence of Four Adverse Outcomes in the Elderly Population: Implications for Home Care Policy and Research

Data From the 1977 National Nursing Home Survey show that more than one fourth of admissions are discharged back to the community. Weighted logistical regression analysis was used to assess the impacts of patient, facility, and contextual characteristics on discharge status. Many facility characteristics appear to have little effect on discharge status. The important exception is the proportion of the homes patients supported publicly, especially by Medicaid. Patients in homes that are heavily Medicaid supported have a significantly reduced chance of community discharge. Profit versus nonprofit status of the facility does not prove to be significant, nor does chain membership. Important patient characteristics are marital status, age, diagnosis, physical dependency, mental disorders, and source of payment for charges. Climate is significant, while occupancy rate is not.

Managed care for elderly people: a compendium of findings.

The article summarizes the shortcomings of current home care targeting policy, provides a conceptual framework for understanding the sources of its problems, and proposes an alternative resource allocation method. Methods required for different aspects of the study included synthesis of the published literature, regression analysis of risk predictors, and comparison of actual resource allocations with simulated budgets. Problems of imperfect agency ranging from unclear goals and inappropriate incentives to lack of information about the marginal effectiveness of home care could be mitigated with an improved budgeting method that combines client selection and resource allocation. No program can produce its best outcome performance when its goals are unclear and its technology is unstandardized. Titration of care would reallocate resources to maximize marginal benefit for marginal cost.

Heterogeneity of risk in a managed home health care population

Issues related to measuring outcomes of care in geriatric evaluation and management (GEM) units were identified by the outcomes working group of the GEM evaluation conference. GEM units have as a major goal the improvement or maintenance of both physical and psychosocial function. Suggested outcome measures for physical health included survival, restricted activity days, general health perceptions, comprehensive physical function, and miscellaneous specific types of functioning. In the area of psycho‐social function, the working group suggested measuring cognitive function, affect/life satisfaction, social function, and satisfaction with care. The patients caregiver (eg, spouse or child) is often an important target of GEM care, and the group suggested measuring caregiver burden, life satisfaction, and assessment of patient behavior problems.