Home Care Provision and Quality of Life among Older Adults

Abstract

Home care is a non-institutional type of long-term care service. Provision of home-based long-term care (also known as personal care service) includes a range of activities of daily living (ADL) assistance and instrumental activities of daily living (IADL) assistance provided to individuals with disabilities and chronic conditions, enabling them to stay in their homes and communities and to maintain independence. The growing number of older adults and people with disabilities have increased the demand for long-term care services and driven up costs. To absorb the increasing demand for long-term care and lower the high spending on institutional care, Medicaid-funded home care has expanded to meet the demand. Medicaid-funded home care programs provide individualized personal care and home-making services to people with functional limitations and help them remaining at their own residence as long as possible in hopes of promoting quality of life of service recipients and delaying their need for institutional care, particularly among older adults. The purposes of this study were to describe the quality of home care and explore how it might influence quality of life and nursing home placement. The specific aims were to: (1) describe quality of home care of Medicaid-funded home care programs and the factors that influenced quality of home care from case managers’ perspectives. (2) examine the relationships between provision of home care and quality of life outcome measures (i.e., self-rated health status and well-being index) over four years of follow up among Medicare-beneficiaries who were 65 years and older. (3) estimate the odds of long-term nursing home placement by the number of activities of daily living tasks needed and received, while accounting for death as a competing risk event, among Medicare-beneficiaries who were 65 years and older. This dissertation included a qualitative interview study and two secondary analyses of longitudinal survey data derived from the National Health and Aging Trends Study. The qualitative study involved individual interviews with 11 case managers, who were practicing case management in home care programs in Washington State. The two secondary analyses addressed two research questions. One analysis explored the associations of home care service with self-rated health status and well-being. Another analysis examined the effect of home care service on the odds of nursing home placement in a cohort of 6004 home-dwelling older adults. The study findings demonstrated a five-level ecological influence on quality of home care and suggested a linkage between quality of home care and quality of life of older service recipients. Home care service was statistically nonsignificant, but positively associated with self-rated health status and well-being. Significant associations were found between the number of activities of daily living assistance needs and self-rated health status and well-being. Finally, the incidence of nursing home placement was lower for individuals with formal activities of daily living assistance than individuals without such assistance, while accounting for death as a competing-risk event. The incidence of nursing home placement was higher for individuals with informal activities of daily living assistance, increasing age, and increasing number of medical conditions. Future research is needed to develop a set of measures for home care quality and service outcomes, as well as to link home care quality to outcomes.