Conclusion
An important factor to note in this study is that
much of the variance in the prescription of services
remains unaccounted for. One reason may be that
our assessment instruments are imperfect and are
unable to finely capture all the information that care
planners may utilize in decision making. Discussions
with the program staff offered client preferences as a
possible source of variation in service prescription.
For example, occasionally an older client will refuse a
home health or personal care aide because the client
wants the family member (usually a daughter) rather
than a stranger to attend to such "personal" needs.
Such a client, however, may accept other services.
Studies on long-term care utilization have tended
to assign clients a rather passive role in the prescription
of home care services. That is, the clients bring
their "characteristics" (demographics, ADL abilities,
informal resources, etc.) to the assessment table,
which are then acted upon by the care planner who
assigns the needed services in keeping with program
guidelines. What is missing from this picture is an
understanding of what role the client actively plays in
negotiating the final care plan. Thus, a study of the
actual care planning process in CCSP may be warranted.
Although client preference or attitudinal variables
were not available in the current care plans, the
potential for including such variables in the client'srecord does exist, which could provide much
needed information on the role of the client in the
decision-making process.
From the data on service packages and volume of
services, we see that users of in-home care are a
diverse group who need a variety of services of
varying combinations and frequencies to help them
stay in the community. Thus, flexibility in determining
service packages will continue to remain an important
feature of long-term care programs. One of
the useful features of the case-managed waiver program
appears to be the ability of the program to
provide for services that would normally require
eligibility to participate in programs funded by at
least two different sources — Medicare and OAA/
Title III. The assessment team in CCSP appears to be
able to offer service packages for long-term care in
combinations that otherwise might have been difficult
to access by this group of poor and frail older
people.
The issue for future program evaluation would be
to determine whether individuals who are prescribed
low levels of home care services are perhaps
benefiting from participation in the waiver program
in other ways. For example, what exactly do nursing
services provide on a once-a-month basis? Does the
provision of this monthly monitoring service prevent
more acute problems later? The lack of literature on
examining outcomes in the context of services delivered
remains a major gap in our knowledge of community-
based care. More work is needed on developing
an understanding of expected outcomes for
the prescription of various services and service packages.
Perhaps we can begin by having care planners
indicate expected outcomes for each client at a given
level of service. We need to move from simply looking
at delay or prevention of nursing home placement
to other benefits that may be accruing as a
result of community-based care.
Conclusion
An important factor to note in this study is that
much of the variance in the prescription of services
remains unaccounted for. One reason may be that
our assessment instruments are imperfect and are
unable to finely capture all the information that care
planners may utilize in decision making. Discussions
with the program staff offered client preferences as a
possible source of variation in service prescription.
For example, occasionally an older client will refuse a
home health or personal care aide because the client
wants the family member (usually a daughter) rather
than a stranger to attend to such "personal" needs.
Such a client, however, may accept other services.
Studies on long-term care utilization have tended
to assign clients a rather passive role in the prescription
of home care services. That is, the clients bring
their "characteristics" (demographics, ADL abilities,
informal resources, etc.) to the assessment table,
which are then acted upon by the care planner who
assigns the needed services in keeping with program
guidelines. What is missing from this picture is an
understanding of what role the client actively plays in
negotiating the final care plan. Thus, a study of the
actual care planning process in CCSP may be warranted.
Although client preference or attitudinal variables
were not available in the current care plans, the
potential for including such variables in the client'srecord does exist, which could provide much
needed information on the role of the client in the
decision-making process.
From the data on service packages and volume of
services, we see that users of in-home care are a
diverse group who need a variety of services of
varying combinations and frequencies to help them
stay in the community. Thus, flexibility in determining
service packages will continue to remain an important
feature of long-term care programs. One of
the useful features of the case-managed waiver program
appears to be the ability of the program to
provide for services that would normally require
eligibility to participate in programs funded by at
least two different sources — Medicare and OAA/
Title III. The assessment team in CCSP appears to be
able to offer service packages for long-term care in
combinations that otherwise might have been difficult
to access by this group of poor and frail older
people.
The issue for future program evaluation would be
to determine whether individuals who are prescribed
low levels of home care services are perhaps
benefiting from participation in the waiver program
in other ways. For example, what exactly do nursing
services provide on a once-a-month basis? Does the
provision of this monthly monitoring service prevent
more acute problems later? The lack of literature on
examining outcomes in the context of services delivered
remains a major gap in our knowledge of community-
based care. More work is needed on developing
an understanding of expected outcomes for
the prescription of various services and service packages.
Perhaps we can begin by having care planners
indicate expected outcomes for each client at a given
level of service. We need to move from simply looking
at delay or prevention of nursing home placement
to other benefits that may be accruing as a
result of community-based care.
การแปล กรุณารอสักครู่..
