I want to live here for rest of my life. The challenge of case management for rural seniors

The research on long-term care for seniors clearly demonstrates that efforts to integrate urban case management services with elderly people living in rural settings have not been successful. Presenting findings of the Rural Seniors Assisted Living Study conducted in northwestern Ontario, Canada, this article demonstrates the complexity of providing health and social services for seniors living in small rural communities, services that are often vastly different from those provided in urban communities. The article proposes a specialized Rural Case Management approach with rural elderly clients and identifies four intervention roles: providing direct service, consulting extensively with specialists of other disciplines, constructing and supporting natural helping networks, and resource management. The approach also requires that the rural case manager assume a leadership role at the community level in the development of services for seniors. Having a locally based case manager rather that a case manager who travels out to rural areas from an urban center is essential to the success of this rural case management approach. Finally, the article contends that rural case management differs from urban case management by requiring specialized knowledge, skills and educational programs.     

Spending-down to Medicaid in the nursing home and in the community. A longitudinal study from Monroe County, New York

Medicaid spend-down continues to be of considerable interest in public policy discussions regarding long-term care financing reforms. Yet, "measuring" of spend-down has been difficult because of data limitations. This study focuses on patterns of spend-down affecting those who become Medicaid eligible both in nursing homes and in the community. The study uses a longitudinal, person-specific, merged Medicare and Medicaid claims and eligibility file constructed for Monroe County, New York. The analyses show that 27% of those who enter nursing homes as private pay can be expected to spend-down to Medicaid while in a nursing home. The spend-downers remain in nursing homes for a prolonged time, with 63% staying for more than 3 years. On admission, spend-downers appear somewhat more likely than those who remained private pay or Medicaid throughout to have been less disabled in terms of activities of daily living (ADL). The community-based spend-down group is larger, younger, and more heavily represented by those who are poor or marginally poor, than the nursing home-based spend-down population. Their spend-down to Medicaid appears to have been triggered principally by the cost of acute medical care not covered by Medicare or another third-party payer. It is this population of the elderly that would have been the principal beneficiary of the short-lived 1989 Medicare Catastrophic Coverage Act. The results of this study indicate that neither the existing private long-term care insurance policies nor the currently circulating public coverage proposals alone are sufficient to protect older persons, at risk of spend-down to Medicaid, from impoverishment. Effective long-term care financing reform will need to create partnerships between public and private insurance, rather than look at them as competing options.     

Inequality in men's mortality: the socioeconomic status gradient and geographic context

Lower mortality for older rural Americans, compared to urban residents, runs counter to rural-urban disparities in health care services and residents' socioeconomic resources. This paradox calls into question the ways in which community conditions influence mortality and contextualize the relationship between individuals' socioeconomic status and health. Drawing on 24 years of data from the National Longitudinal Survey of Older Men, we observe that rural older men's life expectancy advantages occur even after controlling for residential differences in social class and lifestyle factors. Our results also show that rural advantages in mortality coincide with a more equitable distribution of life chances across the social classes. The association between social class and mortality is strongest among urban men, arising from socioeconomic conditions throughout the life cycle.     

The health and welfare system for elderly in France

Dichotomy is the main characteristic of the Health and Welfare system in France. This system lies on two distinct fields, the medical field which is managed by the National Government, and the social field managed by the Local Government. The French home care policy for the elderly has developed a large number of services to assist in activities of daily living, to provide nursing and medical care at home, to improve living conditions, to maintain social relationships, and to postpone institutionalization and hospitalization, respectively. The main home care service is represented by "home helpers" who provide maid Notiniralics services. The second widely used service is the "home care service" performed by a team of nurses, assistant-nurses, psychologists, physiotherapists. This team provides nursing care and assistance in activities of daily living. As for institutions for the elderly, they are divided into welfare and medical institutions. The welfare institutions include social establishments like shelter homes and nursing homes. The medical institutions are mostly represented by long-term care hospitals. One of the main goals of the aging policy is to create medical wards in welfare institutions in response to the increased dependency of the institutionalized elderly. Recent experimental and innovative concepts have been established, such as "shelter homes for dependent elderly" for physically or cognitively impaired elderly.     

Profile and cost of head injury patients admitted to the Waikato Hospital Intensive Care Unit

AIMS: To examine the profile and hospital costs of head injury patients admitted to the Waikato Hospital Intensive Care Unit (ICU). METHODS: Data were collected on head injury patients admitted to ICU over 41 months and costs of head injury patients in ICU, the High Dependency Unit (HDU) and other wards were calculated. RESULTS: There were 286 head injury patients admitted to ICU, of whom 62% had a Glasgow Coma Score < or = 8. Times in the ICU and hospital were 1760 and 7352 days respectively. Costs per day were $2280 in ICU, $800 in HDU and $500 in other wards. The cost for ICU was $1,174,478 per year, and for the total hospital treatment, $2.05 million (83 head injury patients) per year. Admissions of head injury patients to all New Zealand ICUs were 777 over the year to June 1996. Thus, assuming similar costs to the Waikato Hospital, New Zealand hospitals spend each year approximately 10.9 million dollars on head injury patients in ICUs and 19 million dollars on overall hospital stays (including ICU). In a selected group of 123 severe head injury patients, the six month Glasgow Outcome Scores showed that 36% were in the moderate to severe disability categories and likely to cause major ongoing ACC costs. The costs of the 80% of head injury patients admitted to hospital but not admitted to ICU, and their prehospital and postdischarge costs were not studied. CONCLUSIONS: The New Zealand epidemic of head injuries continues to consume large amounts of the health money and produce major social costs.     

Radio-sensitive murine thymoma cell line 3SB: characterization of its apoptosis-resistant variants induced by repeated X-irradiation

This paper describes public health nurses' perceptions of changes in their practice. The participants were 28 public health staff nurses from six Alberta, Canada health units serving urban and rural populations. Data were collected in 1993-94 using individual and focus group interviews. Content analysis was used to identify the following themes: "pulling back", "from hands on to arms length", "handing over responsibility", "developing working partnerships", and "doing less surveillance". These themes are discussed in terms of their implications for population health and for public heath nursing, using as a point of reference the principles of Primary Health Care. Continuing research is needed to chronicle further changes in public health nursing practice that will result from health care restructuring and health system reform.     

Physical abuse among depressed women

BACKGROUND: The evidence-based approach to medical care involves the explicit use of evidence on the magnitude of the effects of interventions to inform diagnostic and treatment decisions. This article critiques current mainstream guidelines on the management of hypertension in the elderly (aged 60 years and over) and presents an alternative evidence-based approach. METHODS: Three major national and international guidelines for the management of hypertension from the United Kingdom (UK), the United States (US) and from a joint World Health Organisation/International Society of Hypertension (WHO/ISH) Working Party were appraised and the evidence on which they were based was reviewed. The relevant evidence was also assessed to determine the likely magnitude of risks and benefits of anti-hypertensive treatment in older people and an alternative approach to making treatment decisions, based on the New Zealand guidelines for the management of hypertension, is described. RESULTS: Hypertension management guidelines from the UK, US and WHO/ISH made similar recommendations about which elderly patients should be treated, although there were some ambiguities in their advice. Treatment recommendations were based primarily on blood pressure levels which were set at about 160 mm Hg systolic and/or 90 mm Hg diastolic. The threshold levels were based mainly on the cut-off blood pressure levels used in randomised trials of anti-hypertensive drug treatment, rather than the estimated magnitude of treatment benefit. Each of the guidelines acknowledged the important effect of associated cardiovascular disease (CVD) risk factors on the likely benefits of treatment, but did not expand on the magnitude of this effect. No patient-specific estimates of the likely absolute benefits of treatment were provided in any of the guidelines. In contrast the New Zealand guidelines for the management of hypertension recommend the use of explicit estimates of absolute CVD risks and benefits to inform treatment decisions. They were designed to provide practitioners with estimates of the likely absolute risk of CVD in patients with different risk factor profiles and with estimates of the absolute benefits of treatment. The New Zealand guidelines recommend that drug treatment be considered in patients with a 5-year risk of CVD of about 10-15% or more; approximately 25 patients with a 10-15% risk would require treatment for 5 years to prevent one CVD event. As elderly patients are generally at higher absolute CVD risk than younger people, the New Zealand recommendation give priority to the treatment of older patients. In order to take account of differences in life expectancy and the medical costs of caring for elderly people, absolute risk-based guidelines can be improved by incorporating potential years of life gained from treatment and the cost-effectiveness of treatment expressed as $/quality adjusted life years gained. Preliminary analyses indicate that the cost-effectiveness of treatment is generally greatest in patients in their 60s and early 70s. Treatment in younger people is not usually very cost-effective because of their low absolute risk of CVD and the cost-effectiveness of treatment in people over about 75 years declines because of the increasing cost of non-CVD morbidity. CONCLUSIONS: The explicit assessment of absolute CVD risks and likely treatment benefits in patients with hypertension can usefully inform treatment decisions and provide a more rational basis for initiating therapy than blood pressure levels alone. This approach highlights the generally greater CVD risk and potential treatment benefits in older compared with younger hypertensive patients. The absolute risk-based approach can be further enhanced by providing decision makers with patient-specific data on the potential life years gained from treatment and its cost-effectiveness. (ABSTRACT TRUNCATED)     

General practitioner funding policy: from where to whither?

Six public policy objectives relating to general practitioner (GP) funding since 1938 have been identified. They concern national health insurance, rural GP shortages, care for the poor, health promotion, cost effectiveness and community control. Each of these objectives is examined in turn, focusing on the extent to which each has been met. In all cases past policies have been, at best, only partially successful in meeting their objectives and have required little in the way of dismantling prior to the introduction of new GP funding initiatives subsequent to 1993. Theoretical principles relating to the development of efficient and coherent public policy are discussed. New Zealand policy relating to funding of GP services has rarely conformed to such principles. There is an emerging consensus between social democrats and libertarians that targeted programmes for the poor is the equitable and efficient way to proceed. A key policy decision concerns the balance between planned primary care services for low income groups and more traditional market style arrangements for others.     

Modeling INR data to predict maintenance fluindione dosage

This paper considers the impact of the distance between employed caregivers and their elderly relatives on the provision of various forms of family-based assistance ("eldercare"), and in so doing it contributes to two overlapping literatures, one on the geography of care for elderly persons and the other on eldercare as a "work and family" issue. The paper also seeks to interpret and understand the spatiality of eldercare in light of evolving public policy on the care of dependent populations, and does so with an eye to the highly gendered nature of family caregiving. The empirical portion of the paper draws on a national survey of work and family conducted by CARNET (The Canadian Aging Research Network). Analysis of data for 1149 respondents with eldercare responsibilities reveals significant distance-decay effects in the average (weekly) number of hours devoted to eldercare. However, disaggregation by gender reveals that only male caregivers display this normative behaviour. Analysis of the average time-distances at which particular types of assistance are provided reveals a similar "gender gap"--women are willing to travel farther, more often, than male caregivers. The results suggest that the reconceptualization of aging as a "private" problem, to be attended to (by women) in the family and community, will particularly affect the careers and family lives of female caregivers, for they are more likely than their male counterparts to take on more travel and try to squeeze more into already tight time budgets.     

In vitro metabolism of cyanohydroxybutene: formation of a glutathione-S-transferase catalyzed product

This paper examines the financing of elderly health care in Japan for medical institutions, nursing homes, and at home. The analysis demonstrates that the conventional figures for elderly health expenditures in Japan systematically underestimate the real costs by excluding the costs of uninsured services, nursing homes, and home health care. The paper estimates these costs and shows that they add about 10% to the conventional figure for elderly health care costs in Japan. This inquiry also shows how government policy for health care financing shaped distinctive Japanese patterns of elderly care provision. The financing system provided a hidden subsidy--through national health insurance coverage of long-term hospitalization--that encouraged high institutionalization rates of elderly in medical facilities. Public financing for long-term elderly hospitalization, however, has not been matched by government attention to quality of care, resulting in serious quality problems and reflecting a social trade-off between cost and quality. Also, until recently the financing system rarely reimbursed home health care, thereby creating strong disincentives to the development of formal home health care services. This analysis has important implications for reforms now being considered by the Japanese government in the financing and provision of health care for the elderly, especially the limitations of relying on reimbursement price policy. The reforms could have unintended negative consequences for equity, efficiency, and quality of care.     

Anesthesia-induced alteration of small vessel response to norepinephrine

To determine whether foreign medical graduates (FMGs) provide a disproportionate and increasing share of primary care in some rural areas, changes in physician distribution in a rural section of upstate New York over a 20-year period (1953-1973) were evaluated by country of medical education and type of practice. A contiguous urban area was examined for comparison. In 1953, FMGs accounted for a higher proportion of primary care physicians in rural areas (11%) than in urban practice (6%) (p less than 0.01). By 1973, this distribution had increased to 26% rural and 14% urban (p less than 0.001). During the two decades, the number of U.S. medical graduates in primary care declined by 15% in the rural areas but increased by 13% in the urban center. The number of primary care FMGs in this same period increased 88% in the rural area. With a 10% decline in (rural) FMGs trained in developed countries, this net increase in FMGs was accounted for by physicians from developing countries. Primary care physicians trained in the U.S. or in developed countries increased more in the urban center, while physicians from developing countries increased more in rural (53%) than urban (47%) practices. Finally, by 1973, rural primary care physicians were more likely than urban primary care physicians to be from developing countries (p less than 0.001).     

Prevalence of dementia in a rural setting: A report from India

A study to estimate the prevalence of dementia in a rural population was conducted in a community located on the outskirts of Madras city in South India. Seven hundred and fifty elderly 60 years of age and older, selected using the cluster sampling technique, were interviewed using the Geriatric Mental State schedule (GMS). The prevalence of dementia was 3.5%, the percentage increasing with age. These rural prevalence estimates were higher than in urban settings (WHO multicentre study on cognitive impairment and dementia in developed and developing countries, unpublished) and male/female differences were negligible. The difficulties associated with the use of the GMS in a non-literature rural population are discussed. The implications of these findings for India's growing elderly population are highlighted.     

Rules of the game: how public policy affects local health care markets

This paper explores the impact of public policy on local health care systems in a representative sample of twelve U.S. communities. Site visits conducted in those communities suggest that public policy is an important force that shapes health system change, for instance, by establishing the underlying "rules of the game" for private and public actors and by influencing the decisions of national and regional entities to enter and exit local markets. These dynamics are explored through a discussion of several key policy areas, including Medicaid and Medicare managed care programs, state regulation of managed care, regulation of providers' rates, certificate-of-need rules, and oversight of conversions from nonprofit to for-profit status.     

Pathways of dependence: the impact of health and social care restructuring--the voluntary experience

The current emphasis on community over institutionally based modes of health and social care delivery in the UK, together with legislative change, has placed a renewed emphasis on the role of the informal sector in service provision. Simultaneously, there has been an attempt to modify the provider-role of the statutory sector, in favour of an evolving role as purchaser and enabler of independently provided services. Drawing on material that forms part of a 3 year study into health and social care restructuring, and its effect on the caring networks of elderly dependent populations, this paper focuses on the changing role of the voluntary sector. Using empirical material drawn from the Scottish environment, it illustrates how the restructuring process may be modifying the voluntary sector and contributing to a growth in geographical inequity in voluntary service provision. In doing so, it considers four main factors affecting local voluntary organisations--the growth of contracting, external constraints on voluntary provisioning, the influence of the local authority and Wolch's concept of the "Shadow State". It highlights the emerging social and spatial manifestations arising from such change, and how these modifications may also be contributing to a growth in geographical inequity for service recipients linked within the dependence network.     

The Special Committee on Aging and the health care agenda in 1998.

Presents a report from the chairperson on the agenda and health issues for 1998 of the US Senate Special Committee on Aging. With Baby Boomers growing older and living longer than ever before, and with fewer children being born, attention to issues affecting older Americans is growing every day. These demographic trends will change the shape of our public and private retirement income and health arrangements over the next few decades. Topics on the committee's agenda include Medicare's Part A Hospital Trust Fund, the future financial viability of the Social Security retirement program, other long-term care concerns, and the investigation of consumer fraud targeting the elderly. Health issues discussed include the Kassebaum-Kennedy Health Insurance Portability and Accountability Act, employer-provided managed care plans, private contracting in Medicare, the tobacco settlement, and the uninsured. In conclusion, psychologists are urged to get involved in helping Congress make policy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Biophysical characterization of the interaction of the beta-lactamase TEM-1 with its protein inhibitor BLIP

Health care expenditures on the elderly tend to grow about 4 percent per year more rapidly than the gross domestic product (GDP). This could plunge the nation into a severe economic and social crisis within two decades. This paper describes recent growth in age/sex-specific health care utilization by the elderly and discusses the important role of technology in that growth. It also explores the potential for the elderly to pay for additional care through increases in work and savings. Efforts to "save Medicare" will prove to be "too little, too late" unless they are embedded in broader policy initiatives that slow the rate of growth of health care spending and/or increase the income of the elderly.     

A geriatric medical residency program. A four-year experience

Geriatricians are needed to further improve the health care of elderly Americans. The first formalized geriatric residency program in the United States was developed at the Mount Sinai City Hospital Center in New York, and this has produced a second program at the Jewish Institute for Geriatric Care at Long Island Jewish-Hillside Medical Center, New Hyde Park, New York. The goals of this training are to develop special clinical skills to deal with the medical and psychosocial problems of the elderly, and to achieve the ability to develop health care systems for the elderly. Emphasis is on a multileveled system, including home, outpatient, acute hospital, convalescent unit, and long-term institution care. The training period is 12 to 24 months, after an initial 24 to 36 months of standard internal medicine, thus fulfilling the requirements for board eligibility in internal medicine.     

Perceptions of urban versus rural hospital patients about return to their communities

During a two-month period in 1976, male patients scheduled to be discharged from two Veterans Administration Hospitals, who were aged 55 or older, chronically ill, able to communicate rationally, and had been hospitalized at least a week for the current illness, were interviewed prior to discharge. Information was sought regarding their feelings about admission and discharge, the availability of and their need for 13 related health-related services at home, and the informal support systems available to them in their local communities. Comparisons were made between patients from distinctly rural settings (communities with less than 5,000 population) and those from larger towns or cities. Both urban and rural patients were modest in assessment of their own health-related needs, especially their need for social and ancillary health services. In almost all instances, the perceived availability exceeded perceived needs. Rural dwellers reported somewhat less apprehension about entering the hospital; they also reported more social contact in their home communities despite the fact that in this sample the rural dwellers were more likely to be older, widowed, and living alone. Rural dwellers were slightly more likely to have their own family doctor.