Larry Polivka - Academia.edu (original) (raw)
Papers by Larry Polivka
Innovation in Aging, Dec 1, 2021
The purpose of this collaborative study between researchers in Japan and the U.S. was to understa... more The purpose of this collaborative study between researchers in Japan and the U.S. was to understand the retirement experience and potential changes in social interactions (amount, type, and mode of communication) among older adults living independently in the community. Specifically, we were interested in individuals' expectations about retirement and the types of social interactions experienced prior to and post-retirement, situated within the context of the COVID-19 pandemic. Both research teams conducted in-depth one-on-one interviews with community-residing retired older adults in early 2021. In the findings we explore similarities and differences between the retirement experiences of Japanese and American older adults, including methodological differences that transpired; specifically, we evaluate the meaning and experience of the COVID-19 pandemic in each of these cultural contexts and how retired older adults experienced its impact in their social interactions.
Innovation in Aging, Dec 1, 2020
Innovation in Aging, Nov 1, 2019
Alzheimer's disease (AD) is the leading cause of age-related dementia, yet no treatment exists. A... more Alzheimer's disease (AD) is the leading cause of age-related dementia, yet no treatment exists. AD is heterogeneous, and is resultant of the dysregulation of many genetic and biological processes. To decipher this complexity, we leveraged the first translational mouse population of AD to identify 15 gene networks related to individual differences in cognitive outcomes. Using QTL mapping, we also identified a novel putative driver of a module, Gstk1, highly conserved in humans that also significantly correlated with memory outcomes. Together, these transcriptional networks provide new mechanistic insight into the biological processes that regulate individual differences in cognitive function across a genetically diverse population. We could identify how demographics (age, sex, causal AD mutations) influence these modules and how they relate to cognitive outcomes. Finally, the high degree of conservation between our mouse modules to human modules reflects the translatability of our model to human AD, adding to its face validity.
Innovation in Aging, Jun 30, 2017
Through an ACL grant to NYS Office for the Aging in 2012, multiple partners implemented Enhanced ... more Through an ACL grant to NYS Office for the Aging in 2012, multiple partners implemented Enhanced Multidisciplinary Teams (E-MDTs) that included forensic accountants and geropsychiatrists to address cases of elder financial exploitation in two pilot locations in Manhattan and seven counties in upstate NY. This presentation will address findings regarding the efficacy of E-MDTs in investigating and intervening in cases of elder financial exploitation. Outcomes examined included recovery of assets and asset protection. Of the 221 cases reviewed by E-MDTs in both sites between 4/2013 through 12/2015, key outcomes were documented in 103 cases. Reduction of exploitation of assets was reported in 81.5% of cases; an end to exploitation in 68.9% of cases, and restitution or recovery of assets in 16 cases. In the upstate site, the project realized $530,000 in court-ordered restitution and formal repayment agreements. Findings demonstrate the importance of including forensic accountants and geropsychiatrists in E-MDTs.
Innovation in Aging, Jun 30, 2017
Illinois Objectives. The Elder Abuse Decision Support System (EADSS) was designed to meet the cri... more Illinois Objectives. The Elder Abuse Decision Support System (EADSS) was designed to meet the critical need for improved methods for assessment and substantiation of elder mistreatment, using a web-based system with standardized assessment measures. Methods. Six Illinois agencies participated in the field test. One-year pre/post analyses assessed substantiation results, using Illinois' standard investigation procedure as a comparison. Pre/post acceptability was assessed with caseworkers. Focus groups with APS staff examined users' experiences. Validity of measures was assessed using Cronbach's alpha and receiver operator characteristic curve analyses with final substantiation decision as criterion. Results. Increased substantiation of abuse was found. Regarding acceptability, the two systems were found to have differing strengths and weaknesses. Outcome measures had high validity estimates while focus groups indicated directions for improvement. Significance. This study was a successful proof of concept that data collected in the field would be useful for clinical purposes as well as for research.
Innovation in Aging, Jun 30, 2017
Generations, Apr 1, 2001
Both workforce and resources are affected. What will the longterm-care workforce look like in the... more Both workforce and resources are affected. What will the longterm-care workforce look like in the future? The answer to this question is not as straightforward as it might at first seem. The answer depends upon the changing values on which long-term care itself is based. This essay will argue that there are some major changes under way that may frame long-term care in new ways in the future, thereby affecting both workforce and resources. Pyke and Bengtson (1996), reporting on a three-generation study, examine some values of children and grandchildren in Southern California caring for their older relatives and contrast two approaches to caregiving. The "collectivist" approach emphasizes the importance of strong kinship ties, familial responsibilities, and commitment, thereby elevating family caregiving as a desirable and worthwhile activity. In families characterized by this approach, second- and third-generation family members tend to give and offer more help than their older relatives need or appreciate. The "individualist" approach, by contrast, emphasizes independence, self-reliance, and autonomy offamily members. Families characterized by this approach tend to have looser family ties, less frequent contact, and lower personal commitment to one another. Here, second- and third-generation family members turn sooner to formal caregiving services and facilities when the burden of caring increases. While most families have some elements of both collectivist and individualist approaches, an examination of the two is useful in attempts to understand care and values. Significantly, Pyke and Bengtson note that today's third-generation adult grandchildren have grown up in an era more individualist than those of immediately preceding generations, suggesting that a cultural change in values may affect caregiving in the future. Indeed, this is exactly the point of this speculative essay. The discussion of macro-level cultural change carries with it a special burden. Culture is not uniform, even in the changes that are moving through it. In a society such as ours that is built upon and embraces diversity of many kinds, it would be foolish to assume that value changes are ever embraced uniformly. Trends beget counter-trends. And the lenses through which we interpret changing values contain subjective filters colored by ideology and special interests. Nonetheless, the population, technological and organizational origins of changes in values in the United States during the past half century are by now evident. THE CHANGING CONTEXT OF VALUES The tendency to reify as a distinct group those people bom between 1946 and 1964., "the baby boom," treating them as a separate entity, undif ferentiated among themselves, is philosophical wrong-headedness and ignores the rich diversity of this group. Still, the shared experience of the early baby boomers of the urban middle class is undeniable. The first half of the large eighteen-year birth cohort pressed against all institutional structures as it aged, like the surge of a tidal wave. Schools on all levels, the job and housing markets, and the market economy itself all felt the pressure. Members of this birth cohort challenged tradition at every turn. Russell (1993) argues that greater value is given to independence, the entrepreneurial spirit, and personal empowerment among middle-class baby boomers than among their parents. Also, among early baby boomers, there is a greater distrust of authority of all kinds, less company and brand loyalty, greater value for leisure over work and informality over formality, and a more relativistic understanding of ethics. The second or trailing half of the baby boom came to be characterized as inwardly turned, private, self-interested, the "me" generation that greatly valued its personal leisure time. One highly visible segment of this birth cohort came to be known as yuppies. It may be argued that technological and organizational change, rather than population change alone, fostered these outcomes. …
PubMed, 1998
As a researcher and polly analyst in aging, I have been puzzled by the wide and arguably growing ... more As a researcher and polly analyst in aging, I have been puzzled by the wide and arguably growing gap between, on the one hand, what we know about the long-term-care preferences of the elderly for community-based alternatives to institutional care and about our capacity to provide these alternatives cost effectively and, on the other hand, the kind of care, mostly institutional, we have in fact made available. Even though over the last several years we have learned how to make community-based programs affordable, long-term care remains dominated by nursing homes in the vast majority of states. This failure to use what we know to change long-term care in ways vastly preferred by those at greatest risk of needing care (the frail elderly) reflects less a gap in knowledge than a lapse of moral imagination. We have not paid sufficient attention to the ethical dimension of the debate over healthcare policy for the elderly, especially the frail elderly with chronic conditions and impairments requiring long-term care. We have been absorbed with cost-containment, efficiency, and costeffectiveness issues and have tended to pay little attention to the many ethical and moral assumptions inherently related to these issues, which are most commonly treated as technical matters. I think this situation is a manifestation of what Taylor (1991) has described as the domination of"instrumental reason"-pure, self-verifying rationality, mathematical calculations, for example, divorced from messy real life-in the conduct of contemporary policy studies and in policy making. Instrumental reason, as described by Taylor, has dominated our thinking about long-term-care policy and practice. Many of us, I think, have long believed that we were just one or two big studies short of having the evidence needed to make a conclusive case for the cost-effectiveness of home- and community-based alternatives to nursing homes and the creation of a consumer-oriented long-termcare system. I am now convinced, however, that we cannot rely on either cumulative learning from multiple research projects or a "big bang" breakthrough (the big study) to achieve a basic change in long-term-care policy In other words, the science of long-term care will not do the work of the moral imagination in the development of a long-term-care system that is fundamentally responsive to what the frail elderly and their caregivers want and deserve. We already have a body of research that demonstrates the capacity of community-based programs to serve the seriously impaired in a cost-effective fashion. These studies have found that by making available certain services to highrisk recipients in increased quantities (number of nurse visits, hours of homemaker services, etc.) community programs may reduce nursing home use. Findings reported in recent articles by Jette, Tennstedt, and Crawford (1995), Greene and colleagues (1995), and Weissert (1995, I997) indicate that certain mixes of clients and services have the potential to reduce nursing home use substantially. We certainly need more research like these studies. We should not, however, expect that the results of research alone will create sufficient conditions for a profound change in the direction of long-term-care policy. Such change will require a collective change of heart that is fundamentally dependent on the creation of a clear moral vision for long-term care. Research can help us identify the most efficient and consumerresponsive methods of achieving policy priorities inherent in a moral vision. Research is not, however, a substitute for the kind of moral reasoning we need to undertake as a community. We must be mindful of fiscal constraints, but not to the extent that the only option most older people end up with is institutional care. And, as is well described by George Agich (I993) in his discussion of autonomy and long-term care, we must abandon our "all or nothing" attitude toward autonomy and independence: The lack of adequate long-term care insurance, induding home care services and support in this country, often makes illness or disability for elders an all or nothing choice: either one accepts full dependence in a hospital or nursing home because medical problems are not attended to in a timely fashion, or one struggles with the functional disabilities associated with the illnesses of being old without adequate care until disaster arrives. …
Public Administration Review, May 1, 1981
The present discussion reports on some of the first statewide data gathering and analysis to asse... more The present discussion reports on some of the first statewide data gathering and analysis to assess the consequences of the 1975 reorganization of the Florida Department of Health and Rehabilitative Services. Two major concepts guiding the reorganization were: (1) integration of services in order to cover more adequately the needs of clients, including "multi-problem" clients, and (2) decentralization of administrative authority of all programs under a single, district-wide management structure. Despite widespread interest in the Florida system, and two previous studies, no systematic, detailed study of the impact of reorganization at the service delivery level has been conducted until now. The results of this study indicate that departmental employees perceive substantial decentralization of authority and progress toward integration of services since the 1975 reorganization. Perceived improvement in client services is also indicated. Major factors cited as influential in the change are the move toward collocation of services, the establishment of administratively interlinked service networks, and to a lesser extent, the development of generalist managers.
Gerontologist, Sep 23, 2017
Publicly (mainly Medicaid) funded long-term care (LTC) services have evolved from a nursing home ... more Publicly (mainly Medicaid) funded long-term care (LTC) services have evolved from a nursing home dominated system of service to a much more balanced system including home-and community-based services (HCBS) programs over the last 30 years. The HCBS programs have been largely administered by the state and local level nonprofit aging networks (ANs) consisting of Area Agencies on Aging and thousands of service providers. Over the last decade, however, for-profit HMOs administered primarily by large insurance companies have begun to displace AN organizations. State policymakers have embraced for-profit privatizations under the rationale that this approach will generate greater savings, efficiencies, and higher quality outcomes than the traditional public or private nonprofit models of program administration. As we show here, there is very little evidence for this rationale; yet, this lack of evidence has not prevented the continuing growth of for-profit managed LTC programs supported more by an ideology of market fundamentalism than empirical evidence. We also describe six possible consequences of the trend toward corporate control of public LTC services in the years ahead.
The Encyclopedia of Adulthood and Aging, Dec 20, 2015
Ageing & Society, Sep 1, 1996
The focus in the United States on ‘setting limits’ to the provision of such services as health ca... more The focus in the United States on ‘setting limits’ to the provision of such services as health care for old people may be spreading to Europe. This article points up the empirical deficiencies in some of the unexamined assumptions in such proposals, especially the belief that an inordinate share of medical expenditures occur in the final weeks or months of elderly patients. The setting-limits doctrine is viewed as a subset of broader socio-political-ideological thrusts aimed at (or resulting in) anti-elderly, intergenerational-conflict policy proposals. Such proposals should be evaluated in terms of their social constructionist, partially contrived, and historically distorted bases. Apocalyptic gerontology needs to be weighed in terms of its moral implications.
Health Care Management Review, Apr 1, 2004
The objective of this study is to examine the litigation experience of twenty-eight nursing homes... more The objective of this study is to examine the litigation experience of twenty-eight nursing homes in Hillsborough County, Florida. Primary data were collected from Hillsborough County Circuit Court's Clerk's Recording Computer System about lawsuit activity from 1996 to 2000 and linked to the Centers for Medicare and Medicaid Services Online Survey, Certification, and Reporting system. We found that registered nurse levels, size, and being part of a chain or system impacted litigation in Hillsborough County. O n May 15, 2001, Florida Governor Jeb Bush signed into law Senate Bill 1202. This marked the end of a long and sometimes bitter tug of war between Florida's nursing home industry, Trial Lawyer's Association, insurers, citizens, and public interest groups. Senate Bill 1202 was designed to initiate a comprehensive reform of the way long-term care is provided in the state. A growing elderly population, shrinking Medicaid budgets, and concerns about the quality of care in nursing homes were at the forefront of the legislative agenda. Nursing home and assisted living facility (ALF) industry complaints about increasing litigation and liability costs further motivated state government action to ensure the future viability of Florida's long-term care system. The legislation targeted reforms at nursing homes, ALFs, and, to a lesser extent, in-home care. Senate Bill 1202 increased required staffing levels to improve resident care, provided for harsher consequences for poor quality of care, and altered Florida Statutes x400.022-400.023 (the Resident Bill of Rights) so that plaintiffs could still have remedies through the court system but within certain limitations on punitive damages and automatic recovery of attorney's fees.
Innovation in Aging, 2021
The face of public long term care (LTC) funded largely through the Medicaid program is changing r... more The face of public long term care (LTC) funded largely through the Medicaid program is changing rapidly in the U.S. Over the last decade, most states have moved to managed LTC programs in various forms, with a growing number transferring all their programs, home and community based (HCBS) and nursing home services, to a Medicaid (MLTC) model. The amount of rigorously conducted and reported evaluation results on these programs are still very limited. Enough information is available, however, from other sources for at least preliminary comparison of relative cost-effectiveness of MLTC vs. traditional, non-profit models of public LTC services delivery and financing, as discussed in this paper. This comparison will show that, at this point, the MLTC programs are not more cost-effective than the traditional model of LTC administration. In fact, these initial assessments seem to indicate that the traditional model may be superior to the corporate for-profit MLTC model.
Florida State University Law Review, 1991
hassee, Fla.). Approximately 1/3 of all CCE clients would be placed in nursing homes if not for t... more hassee, Fla.). Approximately 1/3 of all CCE clients would be placed in nursing homes if not for the services provided by the CCE Program. Id. 5. Id. 6. Id. 17. PEPPER COMMISSION PART A, supra note 14, at 6. Activities of daily living include bathing, toileting, walking, and eating. Id. 18. The aging network in Florida presently consists of the HRS Aging and Adult Services program, area agencies on aging, community care for the elderly lead agencies, and a large number of direct service providers.
Journal of Gerontological Social Work, Apr 20, 2004
SUMMARY Federal and state governments face a significant challenge in meeting the long-term care ... more SUMMARY Federal and state governments face a significant challenge in meeting the long-term care needs of an older population that will double in size between 2000 and 2020 and continue to increase through 2050. States have made significant improvements in their long-term care systems for the elderly. However, they are still spending a significant proportion of their long-term care funds on nursing homes. Any effort to improve long-term care for the elderly qualitatively, and not just on the margins, must be focused on developing a more flexible and balanced long-term care system that is responsive to consumer choice. The Aging Services Network is poised to play a significant role in this transformation process. The strengths of the Network include the ability to develop and manage consumer-driven community-based programs; to assess the needs and resources of individual older persons and provide cost-effective community supports; to operate within fixed, capped budgets; and to identify and maintain roles for informal caregivers. Now is the time for national aging organizations, state units on aging, and area agencies on aging to use existing opportunities to move towards the establishment of a balanced system of long-term care.
Innovation in Aging, Nov 1, 2018
A control group is an essential element in the design and conduct of a randomized controlled tria... more A control group is an essential element in the design and conduct of a randomized controlled trial, yet few participants wish to subject themselves to a sham treatment or placebo condition. The Tele-Savvy Healthy Living Attention Control Group was created with this in mind and with respect for and acknowledgment of the busy day to day lives lead by caregivers who are providing care to a person with dementia. We conducted qualitative interviews with a sample of caregivers following their participation in the seven-week control condition to elicit their perceptions regarding the utility of the program and experience in the group. Specific questions referred to the program's influence on their selfcare behaviors and caregiving experiences. Emergent themes included: (a) good nudge, (b) minimal change in lifestyle, and (c) no time for healthy living. These findings provide behavioral researchers with options to consider when designing control groups within randomized controlled trials.
Gerontologist, Sep 14, 2015
Gerontologist, Feb 1, 2007
Public policy & aging report, Mar 24, 2021
Innovation in Aging, Dec 1, 2021
The purpose of this collaborative study between researchers in Japan and the U.S. was to understa... more The purpose of this collaborative study between researchers in Japan and the U.S. was to understand the retirement experience and potential changes in social interactions (amount, type, and mode of communication) among older adults living independently in the community. Specifically, we were interested in individuals' expectations about retirement and the types of social interactions experienced prior to and post-retirement, situated within the context of the COVID-19 pandemic. Both research teams conducted in-depth one-on-one interviews with community-residing retired older adults in early 2021. In the findings we explore similarities and differences between the retirement experiences of Japanese and American older adults, including methodological differences that transpired; specifically, we evaluate the meaning and experience of the COVID-19 pandemic in each of these cultural contexts and how retired older adults experienced its impact in their social interactions.
Innovation in Aging, Dec 1, 2020
Innovation in Aging, Nov 1, 2019
Alzheimer's disease (AD) is the leading cause of age-related dementia, yet no treatment exists. A... more Alzheimer's disease (AD) is the leading cause of age-related dementia, yet no treatment exists. AD is heterogeneous, and is resultant of the dysregulation of many genetic and biological processes. To decipher this complexity, we leveraged the first translational mouse population of AD to identify 15 gene networks related to individual differences in cognitive outcomes. Using QTL mapping, we also identified a novel putative driver of a module, Gstk1, highly conserved in humans that also significantly correlated with memory outcomes. Together, these transcriptional networks provide new mechanistic insight into the biological processes that regulate individual differences in cognitive function across a genetically diverse population. We could identify how demographics (age, sex, causal AD mutations) influence these modules and how they relate to cognitive outcomes. Finally, the high degree of conservation between our mouse modules to human modules reflects the translatability of our model to human AD, adding to its face validity.
Innovation in Aging, Jun 30, 2017
Through an ACL grant to NYS Office for the Aging in 2012, multiple partners implemented Enhanced ... more Through an ACL grant to NYS Office for the Aging in 2012, multiple partners implemented Enhanced Multidisciplinary Teams (E-MDTs) that included forensic accountants and geropsychiatrists to address cases of elder financial exploitation in two pilot locations in Manhattan and seven counties in upstate NY. This presentation will address findings regarding the efficacy of E-MDTs in investigating and intervening in cases of elder financial exploitation. Outcomes examined included recovery of assets and asset protection. Of the 221 cases reviewed by E-MDTs in both sites between 4/2013 through 12/2015, key outcomes were documented in 103 cases. Reduction of exploitation of assets was reported in 81.5% of cases; an end to exploitation in 68.9% of cases, and restitution or recovery of assets in 16 cases. In the upstate site, the project realized $530,000 in court-ordered restitution and formal repayment agreements. Findings demonstrate the importance of including forensic accountants and geropsychiatrists in E-MDTs.
Innovation in Aging, Jun 30, 2017
Illinois Objectives. The Elder Abuse Decision Support System (EADSS) was designed to meet the cri... more Illinois Objectives. The Elder Abuse Decision Support System (EADSS) was designed to meet the critical need for improved methods for assessment and substantiation of elder mistreatment, using a web-based system with standardized assessment measures. Methods. Six Illinois agencies participated in the field test. One-year pre/post analyses assessed substantiation results, using Illinois' standard investigation procedure as a comparison. Pre/post acceptability was assessed with caseworkers. Focus groups with APS staff examined users' experiences. Validity of measures was assessed using Cronbach's alpha and receiver operator characteristic curve analyses with final substantiation decision as criterion. Results. Increased substantiation of abuse was found. Regarding acceptability, the two systems were found to have differing strengths and weaknesses. Outcome measures had high validity estimates while focus groups indicated directions for improvement. Significance. This study was a successful proof of concept that data collected in the field would be useful for clinical purposes as well as for research.
Innovation in Aging, Jun 30, 2017
Generations, Apr 1, 2001
Both workforce and resources are affected. What will the longterm-care workforce look like in the... more Both workforce and resources are affected. What will the longterm-care workforce look like in the future? The answer to this question is not as straightforward as it might at first seem. The answer depends upon the changing values on which long-term care itself is based. This essay will argue that there are some major changes under way that may frame long-term care in new ways in the future, thereby affecting both workforce and resources. Pyke and Bengtson (1996), reporting on a three-generation study, examine some values of children and grandchildren in Southern California caring for their older relatives and contrast two approaches to caregiving. The "collectivist" approach emphasizes the importance of strong kinship ties, familial responsibilities, and commitment, thereby elevating family caregiving as a desirable and worthwhile activity. In families characterized by this approach, second- and third-generation family members tend to give and offer more help than their older relatives need or appreciate. The "individualist" approach, by contrast, emphasizes independence, self-reliance, and autonomy offamily members. Families characterized by this approach tend to have looser family ties, less frequent contact, and lower personal commitment to one another. Here, second- and third-generation family members turn sooner to formal caregiving services and facilities when the burden of caring increases. While most families have some elements of both collectivist and individualist approaches, an examination of the two is useful in attempts to understand care and values. Significantly, Pyke and Bengtson note that today's third-generation adult grandchildren have grown up in an era more individualist than those of immediately preceding generations, suggesting that a cultural change in values may affect caregiving in the future. Indeed, this is exactly the point of this speculative essay. The discussion of macro-level cultural change carries with it a special burden. Culture is not uniform, even in the changes that are moving through it. In a society such as ours that is built upon and embraces diversity of many kinds, it would be foolish to assume that value changes are ever embraced uniformly. Trends beget counter-trends. And the lenses through which we interpret changing values contain subjective filters colored by ideology and special interests. Nonetheless, the population, technological and organizational origins of changes in values in the United States during the past half century are by now evident. THE CHANGING CONTEXT OF VALUES The tendency to reify as a distinct group those people bom between 1946 and 1964., "the baby boom," treating them as a separate entity, undif ferentiated among themselves, is philosophical wrong-headedness and ignores the rich diversity of this group. Still, the shared experience of the early baby boomers of the urban middle class is undeniable. The first half of the large eighteen-year birth cohort pressed against all institutional structures as it aged, like the surge of a tidal wave. Schools on all levels, the job and housing markets, and the market economy itself all felt the pressure. Members of this birth cohort challenged tradition at every turn. Russell (1993) argues that greater value is given to independence, the entrepreneurial spirit, and personal empowerment among middle-class baby boomers than among their parents. Also, among early baby boomers, there is a greater distrust of authority of all kinds, less company and brand loyalty, greater value for leisure over work and informality over formality, and a more relativistic understanding of ethics. The second or trailing half of the baby boom came to be characterized as inwardly turned, private, self-interested, the "me" generation that greatly valued its personal leisure time. One highly visible segment of this birth cohort came to be known as yuppies. It may be argued that technological and organizational change, rather than population change alone, fostered these outcomes. …
PubMed, 1998
As a researcher and polly analyst in aging, I have been puzzled by the wide and arguably growing ... more As a researcher and polly analyst in aging, I have been puzzled by the wide and arguably growing gap between, on the one hand, what we know about the long-term-care preferences of the elderly for community-based alternatives to institutional care and about our capacity to provide these alternatives cost effectively and, on the other hand, the kind of care, mostly institutional, we have in fact made available. Even though over the last several years we have learned how to make community-based programs affordable, long-term care remains dominated by nursing homes in the vast majority of states. This failure to use what we know to change long-term care in ways vastly preferred by those at greatest risk of needing care (the frail elderly) reflects less a gap in knowledge than a lapse of moral imagination. We have not paid sufficient attention to the ethical dimension of the debate over healthcare policy for the elderly, especially the frail elderly with chronic conditions and impairments requiring long-term care. We have been absorbed with cost-containment, efficiency, and costeffectiveness issues and have tended to pay little attention to the many ethical and moral assumptions inherently related to these issues, which are most commonly treated as technical matters. I think this situation is a manifestation of what Taylor (1991) has described as the domination of"instrumental reason"-pure, self-verifying rationality, mathematical calculations, for example, divorced from messy real life-in the conduct of contemporary policy studies and in policy making. Instrumental reason, as described by Taylor, has dominated our thinking about long-term-care policy and practice. Many of us, I think, have long believed that we were just one or two big studies short of having the evidence needed to make a conclusive case for the cost-effectiveness of home- and community-based alternatives to nursing homes and the creation of a consumer-oriented long-termcare system. I am now convinced, however, that we cannot rely on either cumulative learning from multiple research projects or a "big bang" breakthrough (the big study) to achieve a basic change in long-term-care policy In other words, the science of long-term care will not do the work of the moral imagination in the development of a long-term-care system that is fundamentally responsive to what the frail elderly and their caregivers want and deserve. We already have a body of research that demonstrates the capacity of community-based programs to serve the seriously impaired in a cost-effective fashion. These studies have found that by making available certain services to highrisk recipients in increased quantities (number of nurse visits, hours of homemaker services, etc.) community programs may reduce nursing home use. Findings reported in recent articles by Jette, Tennstedt, and Crawford (1995), Greene and colleagues (1995), and Weissert (1995, I997) indicate that certain mixes of clients and services have the potential to reduce nursing home use substantially. We certainly need more research like these studies. We should not, however, expect that the results of research alone will create sufficient conditions for a profound change in the direction of long-term-care policy. Such change will require a collective change of heart that is fundamentally dependent on the creation of a clear moral vision for long-term care. Research can help us identify the most efficient and consumerresponsive methods of achieving policy priorities inherent in a moral vision. Research is not, however, a substitute for the kind of moral reasoning we need to undertake as a community. We must be mindful of fiscal constraints, but not to the extent that the only option most older people end up with is institutional care. And, as is well described by George Agich (I993) in his discussion of autonomy and long-term care, we must abandon our "all or nothing" attitude toward autonomy and independence: The lack of adequate long-term care insurance, induding home care services and support in this country, often makes illness or disability for elders an all or nothing choice: either one accepts full dependence in a hospital or nursing home because medical problems are not attended to in a timely fashion, or one struggles with the functional disabilities associated with the illnesses of being old without adequate care until disaster arrives. …
Public Administration Review, May 1, 1981
The present discussion reports on some of the first statewide data gathering and analysis to asse... more The present discussion reports on some of the first statewide data gathering and analysis to assess the consequences of the 1975 reorganization of the Florida Department of Health and Rehabilitative Services. Two major concepts guiding the reorganization were: (1) integration of services in order to cover more adequately the needs of clients, including "multi-problem" clients, and (2) decentralization of administrative authority of all programs under a single, district-wide management structure. Despite widespread interest in the Florida system, and two previous studies, no systematic, detailed study of the impact of reorganization at the service delivery level has been conducted until now. The results of this study indicate that departmental employees perceive substantial decentralization of authority and progress toward integration of services since the 1975 reorganization. Perceived improvement in client services is also indicated. Major factors cited as influential in the change are the move toward collocation of services, the establishment of administratively interlinked service networks, and to a lesser extent, the development of generalist managers.
Gerontologist, Sep 23, 2017
Publicly (mainly Medicaid) funded long-term care (LTC) services have evolved from a nursing home ... more Publicly (mainly Medicaid) funded long-term care (LTC) services have evolved from a nursing home dominated system of service to a much more balanced system including home-and community-based services (HCBS) programs over the last 30 years. The HCBS programs have been largely administered by the state and local level nonprofit aging networks (ANs) consisting of Area Agencies on Aging and thousands of service providers. Over the last decade, however, for-profit HMOs administered primarily by large insurance companies have begun to displace AN organizations. State policymakers have embraced for-profit privatizations under the rationale that this approach will generate greater savings, efficiencies, and higher quality outcomes than the traditional public or private nonprofit models of program administration. As we show here, there is very little evidence for this rationale; yet, this lack of evidence has not prevented the continuing growth of for-profit managed LTC programs supported more by an ideology of market fundamentalism than empirical evidence. We also describe six possible consequences of the trend toward corporate control of public LTC services in the years ahead.
The Encyclopedia of Adulthood and Aging, Dec 20, 2015
Ageing & Society, Sep 1, 1996
The focus in the United States on ‘setting limits’ to the provision of such services as health ca... more The focus in the United States on ‘setting limits’ to the provision of such services as health care for old people may be spreading to Europe. This article points up the empirical deficiencies in some of the unexamined assumptions in such proposals, especially the belief that an inordinate share of medical expenditures occur in the final weeks or months of elderly patients. The setting-limits doctrine is viewed as a subset of broader socio-political-ideological thrusts aimed at (or resulting in) anti-elderly, intergenerational-conflict policy proposals. Such proposals should be evaluated in terms of their social constructionist, partially contrived, and historically distorted bases. Apocalyptic gerontology needs to be weighed in terms of its moral implications.
Health Care Management Review, Apr 1, 2004
The objective of this study is to examine the litigation experience of twenty-eight nursing homes... more The objective of this study is to examine the litigation experience of twenty-eight nursing homes in Hillsborough County, Florida. Primary data were collected from Hillsborough County Circuit Court's Clerk's Recording Computer System about lawsuit activity from 1996 to 2000 and linked to the Centers for Medicare and Medicaid Services Online Survey, Certification, and Reporting system. We found that registered nurse levels, size, and being part of a chain or system impacted litigation in Hillsborough County. O n May 15, 2001, Florida Governor Jeb Bush signed into law Senate Bill 1202. This marked the end of a long and sometimes bitter tug of war between Florida's nursing home industry, Trial Lawyer's Association, insurers, citizens, and public interest groups. Senate Bill 1202 was designed to initiate a comprehensive reform of the way long-term care is provided in the state. A growing elderly population, shrinking Medicaid budgets, and concerns about the quality of care in nursing homes were at the forefront of the legislative agenda. Nursing home and assisted living facility (ALF) industry complaints about increasing litigation and liability costs further motivated state government action to ensure the future viability of Florida's long-term care system. The legislation targeted reforms at nursing homes, ALFs, and, to a lesser extent, in-home care. Senate Bill 1202 increased required staffing levels to improve resident care, provided for harsher consequences for poor quality of care, and altered Florida Statutes x400.022-400.023 (the Resident Bill of Rights) so that plaintiffs could still have remedies through the court system but within certain limitations on punitive damages and automatic recovery of attorney's fees.
Innovation in Aging, 2021
The face of public long term care (LTC) funded largely through the Medicaid program is changing r... more The face of public long term care (LTC) funded largely through the Medicaid program is changing rapidly in the U.S. Over the last decade, most states have moved to managed LTC programs in various forms, with a growing number transferring all their programs, home and community based (HCBS) and nursing home services, to a Medicaid (MLTC) model. The amount of rigorously conducted and reported evaluation results on these programs are still very limited. Enough information is available, however, from other sources for at least preliminary comparison of relative cost-effectiveness of MLTC vs. traditional, non-profit models of public LTC services delivery and financing, as discussed in this paper. This comparison will show that, at this point, the MLTC programs are not more cost-effective than the traditional model of LTC administration. In fact, these initial assessments seem to indicate that the traditional model may be superior to the corporate for-profit MLTC model.
Florida State University Law Review, 1991
hassee, Fla.). Approximately 1/3 of all CCE clients would be placed in nursing homes if not for t... more hassee, Fla.). Approximately 1/3 of all CCE clients would be placed in nursing homes if not for the services provided by the CCE Program. Id. 5. Id. 6. Id. 17. PEPPER COMMISSION PART A, supra note 14, at 6. Activities of daily living include bathing, toileting, walking, and eating. Id. 18. The aging network in Florida presently consists of the HRS Aging and Adult Services program, area agencies on aging, community care for the elderly lead agencies, and a large number of direct service providers.
Journal of Gerontological Social Work, Apr 20, 2004
SUMMARY Federal and state governments face a significant challenge in meeting the long-term care ... more SUMMARY Federal and state governments face a significant challenge in meeting the long-term care needs of an older population that will double in size between 2000 and 2020 and continue to increase through 2050. States have made significant improvements in their long-term care systems for the elderly. However, they are still spending a significant proportion of their long-term care funds on nursing homes. Any effort to improve long-term care for the elderly qualitatively, and not just on the margins, must be focused on developing a more flexible and balanced long-term care system that is responsive to consumer choice. The Aging Services Network is poised to play a significant role in this transformation process. The strengths of the Network include the ability to develop and manage consumer-driven community-based programs; to assess the needs and resources of individual older persons and provide cost-effective community supports; to operate within fixed, capped budgets; and to identify and maintain roles for informal caregivers. Now is the time for national aging organizations, state units on aging, and area agencies on aging to use existing opportunities to move towards the establishment of a balanced system of long-term care.
Innovation in Aging, Nov 1, 2018
A control group is an essential element in the design and conduct of a randomized controlled tria... more A control group is an essential element in the design and conduct of a randomized controlled trial, yet few participants wish to subject themselves to a sham treatment or placebo condition. The Tele-Savvy Healthy Living Attention Control Group was created with this in mind and with respect for and acknowledgment of the busy day to day lives lead by caregivers who are providing care to a person with dementia. We conducted qualitative interviews with a sample of caregivers following their participation in the seven-week control condition to elicit their perceptions regarding the utility of the program and experience in the group. Specific questions referred to the program's influence on their selfcare behaviors and caregiving experiences. Emergent themes included: (a) good nudge, (b) minimal change in lifestyle, and (c) no time for healthy living. These findings provide behavioral researchers with options to consider when designing control groups within randomized controlled trials.
Gerontologist, Sep 14, 2015
Gerontologist, Feb 1, 2007
Public policy & aging report, Mar 24, 2021