Toward a Continuum of Caring Alternatives: Community Based Care for the Elderly (original) (raw)
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Medicalization, public policy and the elderly: Social services in jeopardy?
Social Science & Medicine, 1990
This paper examines the medicalization of community-based services for the elderly; a process of restructuring to provide more highly medical services to a frail older population at the expense of providing a broader range of social and supportive services to older persons with varying levels of need. Medicalization is tied to changes in government policy (particularly Medicare reimbursement) which have led to increased competition within the health and social service sector. The paper utilizes data on services, policy impact and staffing from the DRG Impact Study conducted at the Institute for Health and Aging (UCSF), a 3-year study of the impacts of federal policy on 7 types of community providers of services to the elderly. Data are presented from telephone interviews conducted at two points in time (1986 and 1987) with directors of a representative sample of home health agencies (HHAs). Findings include: HHAs were more likely to report adding highly medical services and cited social,supportive services (as opposed to highly medical and/or highly technical services) as the most commonly requested services they cannot provide. Policy effects and societal implications of the medicalization of home care are considered. Key rcords-medicalization. home health, social services, the elderly prospective payment Any discussion of aging and the aging process is invariably linked to a discussion of aging as a health and medical problem. While this tendency to 'medicalize' human conditions and problems is not limited to the experience of aging, the vast and complex origins of this phenomenon may be traced through the treatment of aging in the post-industrial U.S., especially in the past several decades. This paper addresses some of the dimensions of the process of the 'medicalization' of aging by examining the influence of U.S. public policy [especially the Prospective Payment System (PPS) of Medicare], and the resulting changes in hospital behavior on one of the most important components of the post-hospital care system, the home health agency (HHA). The historical and policy context of medicalization are described, including a brief discussion of the macro contextual environment of federal and state policy (e.g. reimbursement policy and its implementation by fiscal intermediaries) and the development of new homecare technologies, both of which have directly affected service provision on the individual agency level.
Financing Long-term Health Care of the Elderly: Dismantling the Medical Model
Public Health Nursing, 1986
Efforts are being made to shift federal financing of longterm care of the elderly from a medical to a health model. The forces of fiscal constraints and an aging population are precipitating a crisis in the current government-financed medical model of longterm care that fosters sending the elderly to institutions. Problems associated with this approach are stimulants to the development of an alternative health model that incorporates nursing, medical, and social components of long term care. Selected govemment-sponsored research in this area has implications for policy. Although project results have been inconclusive in terms of cost effectiveness, they have inspired legislative proposals to effect changes. Several federal bills have potential effects on service delivery and nursing practice in the home and community. Consideration of the issues, proposals, and political climate forms the foundation for strategies to monitor policy options, protect nursing's practice arena, and initiate desired alternatives. Nurses are urged to acquire the information, political skill, and networking capability to become powerful advocates of reimbursement changes that will support consumer needs and the profession's advancement.
1990
The purpose of this project was to compare three different models of building and strengthening community-based systems of care for older adults. Models were distinguished by the type of organization that took the lead in developing the system of services: Area Agency on Aging, acute care hospital, and residential facility. Specific questions addressed in this project were: (1) What conditions in a local community give rise to a community-based system of care (CBSC) for older adults? (2) What are the necessary steps in planning and designing CBSCs? (3) How are successful CBSCs established and maintained? (4) How does the type of lead organization influence a CBSCs accessibility, responsiveness, and effectiveness? (5) To what extent and under what conditions can successful CBSCs be replicated? Answers to these questions were meant to assist leaders in new communities wishing to develop CBSCs for older adults in their own locales. Organizations were selected through a screening process involving mailed questionnaires completed by candidates referred to the project team because of their reputations as successful CBSCs. Questionnaires were designed to measure accessibility (provision of services to all types of older adults), responsiveness (development of new services in response to community needs), and effectiveness (capacity to monitor service impact on client well-being). A total of 15 organizations from as many states were selected for three-day site visits, including five of each type of lead organization. Regardless of geographic location or type of lead organization, key ingredients that gave rise to CBSCs were: individuals with strong visions of a "continuum of care" for older adults; service gaps or fragmentation; local political support for service expansion; and availability of funding from public or private sectors. Planning and design processes were found to be influenced much more by intuition and opportunism than by elaborate data collection and analysis. Successful CBSCs were established and maintained by: retaining key staff for long periods of time; diversifying funding sources; continuing to introduce new services, especially case management; sustaining political support; and effectively managing the expanding range of services. Service decentralization was the strategy used most often by lead organizations to maximize accessibility of their CBSCs. AAAs used public hearings and Advisory Councils to elicit unmet needs for enhancing responsiveness, while hospitals and residential CBSCs responded to needs expressed by individuals desiring alternatives to their core services. To maximize effectiveness, AAAs relied most on contracting protocols while hospitals and residential CBSCs relied most on record reviews. Client feedback was commonly obtained, but automated client tracking systems were not highly developed. Implications of findings focused on conditions facilitating replication of successful CBSCs, and seven recommendations described steps the Aging Network should take to encourage development of CBSCs at the local level. Step 1. Identify successful community-based systems of care. Once a typology of systems based on lead organization was established, the task was to select strong candidates from each system type. National associations representing AAAs, hospitals, and residential facilities, and other experts in the field were invited to nominate potential study-sites. Nominated sites were contacted and asked to complete questionnaires defining and describing their histories, range and volume of services, funding sources, geographical and socioeconomic contexts, and management systems. These screening questionnaires included items used to measure accessibility, responsiveness, and effectiveness of service systems in a standardized fashion. Sites returning questionnaires were subsequently contacted by telephone, and additional documents were assembled and analyzed from each candidate system. The project team developed draft recommendations for a field of 15 study-sites-five from each type. Final decisions were reached with the aid of a National Advisory Panel. The final field of 15 study sites emerged from this process. Their selection was based on evidence of their accessibility, responsiveness, and effectiveness. These study sites were:
Long-Term Care Institutions for Elders and the health system
Revista Latino-americana De Enfermagem, 2007
Creutzberg M, Gonçalves LHT, Sobottka EA, Ojeda BS. Long-term care institutions for elders and the health system. Rev Latino-am Enfermagem 2007 novembro-dezembro; 15(6):1144-9. Objective: Analyze Long Term Care Institutions for Elders (ILPI) organizational social system and its relation to the National Health System (SUS). To identify communication that occurs in the structural couplings between the ILPIs and the SUS and to analyze resonances of the structural coupling between the SUS and the ILPIs. Method: A descriptive, exploratory qualitative study using the functional Niklas Luhmann's method. The data were collected using second order observations, through interviews with seven managers and eight elders, communication analysis of 52 Brazilian ILPIs and third order observations in national literature. Results: The exclusion of the institutionalized elder from the programmed health actions occurs in the health system. There is mutual lack of knowledge between the ILPIS and SUS, and stimulus is necessary for a more successful structural coupling. Conclusions: The little sensitiveness of the SUS regarding the ILPI communications was identified as impediment to the performance of these institutions' social function. DESCRIPTORS: homes for the aged; institutionalization; aged; geriatrics; systems theory LA INSTITUCIÓN DE LARGA PERMANENCIA PARA ANCIANOS Y EL SISTEMA DE SALUD Objetivos: Analizar el sistema social organizacional Institución de Larga Permanencia para Ancianos (ILPI) y su relación con el Sistema de Salud (SUS). Identificar las comunicaciones que ocurren en los acoplamientos estructurales entre la ILPI y el SUS. Analizar las repercusiones del acoplamiento estructural en la ILPI. Método: Estudio exploratorio descriptivo, cualitativo, con la utilización del método funcional de Niklas Luhmann. La recolecta de datos utilizó observaciones de segundo orden, a través de entrevistas con 7 dirigentes y 8 ancianos, análisis de comunicaciones de 52 ILPIs brasileñas y observaciones de tercer orden en literatura nacional. Resultados: En el sistema de salud ocurre la exclusión del anciano institucionalizado de las acciones programáticas en la salud. Hay un desconocimiento recíproco entre ILPIs y SUS, necesitando estímulos para un acoplamiento estructural más exitoso. Conclusiones: La diminuta sensibilidad del Sistema de Salud a las comunicaciones de la ILPI fue identificada como un obstáculo en el desempeño de la función social de esas instituciones. DESCRIPTORES: hogares para ancianos; institucionalización; anciano; geriatría; teoría de sistemas A INSTITUIÇÃO DE LONGA PERMANÊNCIA PARA IDOSOS E O SISTEMA DE SAÚDE Objetivos: Analisar o sistema social organizacional Instituição de Longa Permanência para Idosos (ILPI) e sua relação com o Sistema Único de Saúde (SUS). Identificar as comunicações que ocorrem nos acoplamentos estruturais entre a ILPI e o SUS. Analisar as ressonâncias do acoplamento estrutural com o SUS, na ILPI. Método: Estudo exploratório descritivo, qualitativo, com uso do método funcional de Niklas Luhmann. A coleta de dados utilizou observações de segunda ordem, por meio de entrevistas com 7 dirigentes e 8 idosos, análise de comunicações de 52 ILPIs brasileiras sem fins lucrativos, de caráter público ou privado e observações de terceira ordem em literatura nacional. Resultados: No sistema de saúde ocorre a exclusão do idoso institucionalizado das ações programáticas em saúde. Há desconhecimento mútuo entre ILPIs e SUS, necessitando estimulação para um acoplamento estrutural mais bem sucedido. Conclusões: A diminuta sensibilidade do Sistema de Saúde às comunicações da ILPI foi identificada como entrave no desempenho da função social dessas instituições. DESCRITORES: instituição de longa permanência para idosos; institucionalização; idoso; geriatria; teoria de sistemas
Policy trade-offs in "home care": the Ontario example
Canadian Public Administration/Administration publique du Canada, 1999
As Canada enters the twenty-first century, its highly prized program, medicare, is undergoing radical transformation. With technological change and the restructuring of health systems, the locus of care is shifting from institutions to the home. As a result, care that was formerly publicly financed under the Canada Health Act is technically becoming de-insured. This paper analyses the reform of community-based long-term care services in Ontario from 1985 to the present. During this period, three different parties, the Liberals, the NDP and the Progressive Conservatives, in turn, formed the government. Four different models were put forward before the current model was adopted by the current PC government. Each of these models is analysed with respect to design decisions that must be made in the policy dimensions of financing, delivery and allocation and evaluated in terms of equity, liberty, security and efficiency. Underlying the debate in Ontario was a fundamental disagreement about the role of government, reflected in views about the responsibilities of individuals and their families, and the appropriate place of for-profit organizations within a publicly funded system. The reform of this sector has significance that goes beyond its boundaries, with wider implications and warnings for health care in general.