Sunday, December 28, 2014

Insights into HCB settings controversy: seniors and the continuum of care

I have recently begun to follow a New York Times reporter, Paula Span, at The New York Times Blog “The New Old Age - Caring and Coping”. Paula Span covers issues relating to seniors and their caregivers, who, as it turns out have some things in common with people with developmental disabilities and their caregivers. 

A recent column by Span,  “Dementia, but Prettier”, is a comment on movies that tackle the subject of dementia. She notes that many attractive actresses have taken the leading roles of people being swallowed up by this progressively disabling condition. While praising the acting and some of the films on dementia, Span has doubts that caregivers will see these movies as anything but prettied-up versions of real-life that disguise and deny the realities of the experience.

In another recent blog post, “Unmet Needs Continue to Pile Up” 12/9/14, Span discusses a recent study that compares how well or poorly seniors do in terms of how many needs go unmet across a continuum of living situations. As Span explains,”’Unmet needs,’ …refers to care or help you require but don’t get. If, when you’re elderly or disabled, you aren’t able to shop or cook, you lack the strength to go outside, you can’t keep track of your bank account or your medications — and no one assists you with those functions — you have unmet needs.”

In the debate about whether congregate care can provide people with disabilities the care they need and “integration appropriate to their needs”, the study offers some insight: it all depends on how needy the person is and how well those needs can be met satisfactorily over the continuum. Span also asks the question of whether moving into an assisted living facility or nursing home is worth the extra costs involved in meeting the needs of seniors - “…how often those supposed solutions actually provide enough services to merit their very high price tags. When someone is spending $3,500 a month for assisted living… are there fewer activities the resident can’t manage? Does he or she have fewer unmet needs?”

The national study is entitled
“The Residential Continuum From Home to Nursing Home: Size, Characteristics and Unmet Needs of Older Adults”. It is published in the Journals of Gerontology,  and the authors are Vicki A. Freedman (from our own Institute for Social Research at the University of Michigan) and Brenda C. Spillman. Here are the results of the study as published in the abstract for the Journal: 

"Of 38.1 million Medicare beneficiaries ages 65 and older, 5.5 million (15%) live in settings other than traditional housing: 2.5 million in retirement or senior housing communities, nearly 1 million in independent- and 1 million in assisted-living settings, and 1.1 million in nursing homes. The prevalence of assistance is higher and physical and cognitive capacity lower in each successive setting. Unmet needs are common in traditional community housing [living in one's own home] (31%), but most prevalent in retirement or senior housing (37%) and assisted living settings (42%). After controlling for differences in resident characteristics across settings, those in retirement or senior housing communities have a higher likelihood of unmet needs than those in traditional community housing, while those in independent or assisted living settings have a lower relative likelihood." [emphasis added]
Although it is apparent at first glance that people have more unmet needs in congregate care, the numbers need to be adjusted to take into consideration the higher need for physical assistance and the lower cognitive capacity of seniors in congregate care. This translates into  a lower prevalence of unmet needs in congregate care. This adjustment for the severity of the disabilities, the increasing needs that go with severity, and how well those needs are met over a continuum of settings is often missing in discussions of where is the best setting for people with disabilities to live.

On the issue of costs, Span says of the study result, 

“…[it] looks like a classic good news/bad news finding. On the one hand, seniors and families are getting something for that $3,500 a month and more (frequently way more) in assisted living: Even though they are older and more physically and cognitively impaired, they don’t have more unmet needs than younger, healthier seniors in their own homes.

“The bad news, though, is that unmet needs remain too high in all these settings. In their own homes, in senior housing and retirement communities, in assisted living, lots of people aren’t getting the help they manifestly need.”

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