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This study compared the efficacy of 16 weeks of either resistance training, aerobic walking, or combined resistance training and aerobic' walking on the performance of functional tasks among adults age 65 years and older with limited functional ability. One hundred thirty-one older adult individuals were randomized into four groups: resistance training, aerobic walking, combined resistance and aerobic walking groups, or a nonexercise control group. Each of the exercise groups documented 70% compliance with their respective exercise intervention, which included three weekly exercise sessions. At baseline, and 8 and 16 weeks following baseline, all participants completed six assessments of their functional ability. Analysis of covariance indicated that all three exercise intervention groups significantly improved measures of functional ability, with the resistance group demonstrating the most consistent gains over the six measures. These findings indicate that older adults who are functionally limited can improve their functional ability through a variety of types of exercise. Keywords: older adult; aerobics; resistance training; functional ability

In this study, we examined the effects of gender and pre-bereavement social support from three different sources (spouse, adult children, and friends) on widowhood adjustment among older adults in China. Hypotheses were developed by integrating the literature in the West and the cultural context of China. Data came from a panel survey, conducted in 1991 (baseline) and 1994 (follow-up), of a probability sample of older persons in Wuhan, China. For the present analysis, only those who were married with children at baseline were selected (N = 1,263). About 10% of the sample experienced spousal death between the two measurement points. Multiple regression analyses suggest that widowhood had a negative mental health consequence for older Chinese. Social support from adult children buffered the deleterious effect of widowhood, whereas spousal support during the marriage increased one's vulnerability. Support from friends was not found to have a significant effect. Gender difference in the effect of widowhood was also not evident. In this study, we have extended bereavement and social support research to a developing nation, with some findings similar to and some different from studies in Western developed nations. Keyword: Bereavement; Social support; Intergenerational relations; Spousal support; Older adults; China

To prepare the care system for a rising population of older people, it is important to understand what factors predict the use of care. This paper reports a study of transitions in the use of informal and professional care using Andersen-Newman models of the predictive predisposing, enabling and need factors. The study has drawn on Longitudinal Ageing Study Amsterdam (LASA) data on the use of care and the contextual factors. The data were collected at three-yearly intervals from a random, sex- and age-stratified, population-based sample of adults aged 55-85 years. In summary, the findings for those who initially did not receive care were that almost one-third received some kind of care three years later, most of which was provided by informal care-givers. Need factors were important predictors of most transitions in care, and predisposing and enabling factors, such as age, partner status and income, also played a role. On the relationship between informal and professional care, evidence was found for both 'compensatory processes', i.e. informal care substitutes for professional care, and 'bridging processes', i.e. informal care facilitates professional care. In view of the increasing discrepancy between the demand for professional care and its supply, the significant impact of predisposing and enabling factors offers opportunities for intervention. KEY WORDS--need for care, care transitions, professional care, subsidised care.

A study examined how positive aspects of caregiving affect adaptation to bereavement among older adults who cared for a family member with dementia. The findings show that preloss caregiving benefit was associated with higher levels of post loss depression and grief, even after controlling for caregiver demographic characteristics, contextual factors, and caregiving burden.

Dementia care is in transition, and the potential exists for a radical reform of the provision of services to people with dementia. Recent developments in Scotland based on the report of the Royal Commission on Long Term Care, With Respect to Old Age, provide an example of the possibilities and opportunities available to governments for creating services based on principles of equity and justice. It is timely therefore to consider the implications of recent government reports for the development of dementia care provision. This paper explores the social and political context of formal dementia care provision and considers the implications of recent government reports for the future. The historical discourses surrounding the term 'dementia', and where and who cares for people with dementia, provide insights into the options available to policy makers. A brief exploration of the economic context of dementia care provision, and of the historically low level of political interest in dementia care, provides a backdrop to recent political initiatives that seek to redress this omission. KEY WORDS--dementia, care, dementia services, policy, Scotland.

Access to health care should be determined by clinical need and not by age. Older people form an increasing proportion of the general population and of those with coronary heart disease, but compared with younger people they are less likely to be invited for cardiac rehabilitation programmes and more likely not to complete them. This study examined the factors that contribute to these trends in Scotland. A national survey of rehabilitation centres (n = 30) found that the majority of their programme co-ordinators believe that age does influence access to rehabilitation. While only one programme used an overt age criterion, age was widely perceived to influence access, both during initial assessment and in assessments for exercise components; and while the respondents acknowledged that other criteria influenced selection, the factors cited most often were all more common during old age, e.g. the presence of other medical ailments, lower initial exercise tolerance, and poor access to private or public transport. Focus groups undertaken with a sub-sample of the co-ordinators revealed that staff appeared to have knowledge of the benefits of cardiac rehabilitation for older people, but that the scarcity of resources prevented them from offering more accessible and appropriate services. KEY WORDS--heart, coronary heart disease, prevention, rationing, decision-making, resources.

Care management has become a key component in the development of community-based care in many countries, and this paper examines the different care management arrangements for older people's services that are now emerging. It has been United Kingdom government policy since 1989 that the providers of social services develop care management systems, as confirmed in the White Paper, Modernising Social Services. The paper opens with the background to the policy changes and a discussion of the role of care management in the British social care system. Secondly, evidence from the early phases of care management development is examined; and thirdly, the evidence from a major national study of care management arrangements for older people on the patterns of variation on key dimensions is considered. KEY WORDS--Social care, community care, social services departments, care management, older people's services, United Kingdom.

Objectives. The purpose of this study was to examine long-term trajectories of visits to nursing homes by family caregivers to persons suffering from dementia. Methods. The data were obtained from a 5-year longitudinal study of family caregiving. This analysis used a subsample of caregivers who moved their relatives from home to a nursing home (n = 210). The frequency (times per week) and length (hours per week) of visits for up to 5 years after placement were examined in relation to select caregiver and care-recipient characteristics. A semiparametric, group-based method using a latent class mixture model was used to identify distinctive trajectories over time. Results. The majority of caregivers maintained the frequency and length of their visits for extended periods of time. Five distinct patterns for frequency and three patterns for length were identified. Being a spouse, lower education, a close past relationship, a strong sentiment against placement, and living close to the facility predicted membership in groups visiting frequently and for longer times. Caregiver characteristics were more strongly associated with frequency, whereas care-recipient characteristics were related to length. Discussion. To a large extent, family visits to nursing home residents with dementia become established in the period immediately after relocation, which means that efforts to enhance continued family involvement should commence at the time of admission.

The population structures of many developed countries are changing and shifts towards much older age distributions are common. One way of meeting the resulting increasing demand for long-term care is through small business private sector provision allocated through market systems. However, the private residential care sector in England and Wales demonstrates some of the potential problems of leaving long-term care to the market. During the 1980s, the private residential sector for older persons enjoyed substantial state financed support. Since the 1990 National Health Service and Care in the Community Act introduced markets in social care in 1993, homes have had to compete amongst each other for a much smaller number of clients funded by limited local authority budgets. This impacted on their business and caring operations. Based on a three-stage quasi-longitudinal survey of over 100 residential care homes in one county, this paper considers changes in the overall size and structure of a local sector, discusses the specific management strategies that have been adopted by proprietors and the development of a purchasing and providing market culture. The paper also highlights the importance of interdisciplinary perspectives on the topic by illustrating how changes in social policy can influence local and national geographies of long-term care provision and how, in turn, an understanding of these geographies can inform the sensitive implementation of future social policy initiatives. Keywords: Residential care; Private sector; Markets; Homes; Older people; UK

Purpose: This study describes the Swedish debate on the role of family and state in care of elderly persons. It provides empirical evidence on the shifting balance of family, state, and market in the total panorama of elderly care. Design and Methods: Secondary analysis of older (1954) and more recent data sources (1994 and 2000) is used to assess living arrangements and care patterns for persons 75 years or older living in the community. Results: Total spending on aged adults has stagnated, and institutional care is shrinking in absolute and relative terms, but public Home Help for elders in the community is decreasing even more. Family members increasingly shoulder the bulk of care, but privately purchased care also seems to expand. This study calculates how public and informal care changed between 1994 and 2000: Informal care is estimated to have provided 60% of all care to elders in the community in 1994 and 70% in 2000. Implications: The results parallel a crisis of legitimacy of public elderly care in Sweden. They also call into question various metaphors used to describe patterns of care. Key Words: Informal care, Family, Home Help, Welfare state

Purpose: I examined health and long-term care use trajectories of a sample of chronically disabled older women eligible for both Medicare and Medicaid by exploring their use data in order to understand and anticipate the increasing demand on the health and long-term care delivery systems as aging female baby boomers reach age 65 and older. Design and Methods: A sample of older disabled women in Ohio who completed preadmission review was divided into three groups on the basis of the setting in which they received their initial long-term care services. Results: I was able to establish a long-term care career for the sample members beginning with receiving long-term care in the community, followed by a transition stage in which care was received in the community and in a nursing home, and finally by a stage at which they entered and remained in a nursing home. As the sample members proceeded along their long-term care career and their health and disability status worsened, I found a clear shift in the kind of care needed from hospital and home care to nursing home care. There was also a shift in the major payer, from Medicare to Medicaid. Implications: As the baby boomers age, a much larger number of women will be disabled and need health and long-term care services. For a considerable number of these women, Medicaid gradually becomes the major payer for care, an issue that needs close observation. Key Words: Dual-eligible women, Health and long-term care expenditures, Long-term care career

Background. The Wisconsin Partnership Program (WPP) is a variation on the Program for All-inclusive Care of the Elderly (PACE) model that is designed to be more flexible by allowing frail elderly dual-eligible (for both Medicare and Medicaid) clients to use their regular primary care physicians instead of relying on the physician hired by PACE. Case management is provided by a team of nurse, social worker, and nurse practitioner. The latter is charged with communicating with the client's primary physician. Methods. We compared the functional status and satisfaction of WPP elderly enrollees with those of two sets of dually eligible controls drawn from the Medicaid waiver rosters. One set of controls came from persons in the same county who opted not to enroll in WPP. The second came from matched counties that did not have access to the WPP. Enrollees were interviewed in person. Family members were interviewed by telephone. Results. The prevalence of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) dependency was lower for the WPP sample than that for the controls. The pattern of unmet needs was generally comparable. About half of each sample had a written advance directive. Overall, there were few areas of significant difference in beneficiaries' satisfaction. The WPP families were more satisfied than either control group that services were provided when needed and were better coordinated. There were no significant differences in the prevalence of any aspect of care burden. Conclusions. The impact of WPP seems limited. There is some evidence that families perceive better coordinated care. A more complete evaluation will await the analysis of the differences in utilization patterns between WPP and the controls.

Purpose: This article presents results of a survey of the attitudes and practices of managed care organizations (MCOs) concerning consumer direction. The study focused on understanding several alternative measures of consumer direction and the factors that are associated with the MCOs concerning those measures. Design and Methods: The MCOs that were surveyed provided capitated managed long-term care benefits to their Medicaid-eligible clients and were chosen because personal assistance service is a likely area for consumer-direction interest or practice. Results: Although the majority of the responding MCOs were bund to be practicing some form of consumer direction, the experience is limited and underdeveloped. Two areas of concern seem to be most important in an organization's decision to adopt a consumer choice or consumer-direction model: the balance of concerns about unprofitability and the perceived interest and benefit of the clients. Implications: This study suggests managed care and consumer direction can work together and provides a baseline to assess further development of their compatibility. Key Words: Long-term care, Personal assistance services, Consumer choice, Consumer satisfaction, HMO

The demographic basis for a land dispute between two Tibetan villages in Nubri, Nepal, is examined in relation to family systems. Despite close proximity and sociocultural ties, the villages experience divergent population growth rates resulting from different frequencies of marriage. In one, old-age security concerns induce parents to retain female labor within the household by designating daughters to be nuns, a practice that has the unintended consequence of limiting aggregate population growth by barring many women from marriage and reproduction. In the other village the slightly different family system results in fewer nuns, faster population growth, and a need for more land. Comparisons with family systems and demographic outcomes in Europe and Asia reveal this to be a case in which preventive checks can exist in a context of early marriage and high marital fertility and demonstrate how concerns for old-age security can act as a restraint on aggregate fertility. [Tibetans, family systems, demography, religious celibacy]

Background. In Canada, half the people with dementia live in institutions. Factors associated with institutionalization should be identified with the goal of implementing strategies not only to permit those with dementia to stay in their homes as long as is feasible but also to ensure that steps are taken for timely institutionalization when appropriate. Methods. Informal caregivers of 326 individuals with dementia living in the community were identified and interviewed as part of the Canadian Study of Health and Aging (CSHA). These subjects were contacted again 2.5 and 5 years after the baseline interview to collect information on the status of their care recipients. Survival analyses using clinical data for the individuals with dementia and data from the interviews with their informal caregivers were carried out using Cox proportional hazard modeling to estimate the hazard ratio (HR). Results. Over the 5-year period, 166 individuals with dementia (50.9%) were institutionalized and the median time to admission was 41 months. From the multivariate analysis, the factors significantly associated with institutionalization were: type of dementia (Alzheimer's disease: HR = 1.83), severity of disability (mild: 1.51; moderate: 2.34; total impairment: 4.02), caregiver's age over 60 (1.83), caregiver not a spouse or child (1.55), and severe caregiver burden (1.71). Caregiver's burden was associated with the care-receiver's behavioral disturbance (partial r = .55) and the caregiver's depressive mood (r = .55). Conclusions. Screening caregivers for burden and depression and designing interventions to decrease the consequences of behavioral disturbance on caregivers would be relevant avenues to explore to decrease institutionalization of people with dementia.

The availability of long-term care offered by adult children as informal caregivers to their elderly parents might influence the decision to purchase long-term insurance to cover the costs of nursing home services. Additional information on long-term care insurance coverage is included.

This study assesses consumer-directed home and community services for older persons by examining public programs that serve this population in eight states. These programs give beneficiaries, rather than agencies, the power to hire, train, supervise, and five workers. Most stakeholders interviewed, in addition to the quantitative research, indicate that many older beneficiaries want to and can manage their services, although significant issues arise for persons with cognitive impairments. Research results suggest better, or, at least, no worse, quality of life for beneficiaries when they direct their services, although quality of services remains a contentious issue. For workers, consumer-directed care has some disadvantages, including fewer fringe benefits. With exceptions, state agencies have not provided extensive consumer or worker support or aggressively regulated quality of care.[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: Website: KEYWORDS. Home- and community-based services, long-term care. consumer-directed, disability

Policy regarding long-term care has been an issue of rising national concern. In this paper we examine the transition of Danish long-term care policy with special attention to Skaevinge, the first community in Denmark to integrate institutional and community-based services for the elderly. Recent studies on the variation between costs and services in Danish communities and the results of U.S. studies on community-based care suggest that successful implementation of integrated institutional and community-based long-term care is feasible in the United States. Lessons from Denmark highlight conditions that will facilitate success in this endeavor.[Article (copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: Website: KEYWORDS. Long-term care, nursing home, home- and community-based services, aging

Recently, a growing number of community-based long term care programs have been incorporating a concept of consumer direction (CD). Consumer Direction allows long-term care consumers to take more active roles in the care management, by hiring, training, supervising, and firing care providers. A limited number of existing studies show that CD consumers indeed feel they have more choice and control over their care compared to those under the traditional model. However, others studies show problematic working conditions for care providers under CD. Questions also remain unanswered regarding how CD effects different important stakeholders, including family caregivers, formal paid caregivers, and governments. More research, administrative, and practice efforts are needed to ensure CD can benefit all sectors of communities.

This article presents a tactical protocol to guide social workers and ombudsmen in explaining their conflict behavior in fundamentally imbalanced power structures like nursing homes. It is argued that efficient case advocacy requires the selection of tactics based on the confluence of two conditional factors on a low to high continuum in the following priority: (a) the urgency and severity of the resident's needs, and (b) the facility's level of resistance. Seven possible influence tactics are presented within the broad strategies of relation-building, campaign/collaboration, and contest.

This study examines the assumption that including Black-Americans with larger samples of White-Americans produces an accurate picture of the predictors of nursing home use by Black-Americans. Using the Longitudinal Study of Aging (1984-1990), Cox proportional hazard models are estimated for Black-Americans and White-Americans. This study finds that in fact the models for Black-Americans are not the same as for White-Americans. For Black-Americans, living below the poverty line, problems of functional status, age, and not having the potential for care for a few weeks from relatives (in or out of the home) are predictive of a higher risk of nursing home use while, for White-Americans, age, lower versus higher income, being female versus male, poor evaluation of self health care, poor functional status, lower levels of community activity, and living alone compared to living with a spouse or children were predictive of a higher risk of nursing home admission. The implications for policy and case management practice are discussed regarding these findings.

This article provides an evaluation of Germany's health insurance law regarding the long term care of the elderly. The author, maintaining Germany began to implement new laws in 1995, states that the laws have provided affordable long term care, have restructured community based care, and has created hundreds of new agencies.

Satisfaction with long-term care has received the attention of academics, policymakers, and the general public. However, little attention has been paid to ethnic differences in satisfaction, despite the increasing proliferation of long-term care options and minority representation in such facilities. The authors find that ethnic differences exist in satisfaction with adult care homes. Dependency, satisfaction with health, resident involvement in placement decisions, home type, and percentage of private rooms vary in their impact on satisfaction by ethnicity. Predictors of satisfaction within groups are primarily intra/interpersonal versus organizational characteristics. African Americans are more affected than Whites by organizational factors. Different predictors of satisfaction by ethnicity may indicate that elders bring different life experiences, cultural beliefs, and expectations with regard to long-term care that may influence their degree of satisfaction. Service delivery in long-term care institutions should be aware of the unique experiences of their residents and implement services to ensure optimal satisfaction and care.

Changes in the formal health care system and in the health of the population are likely to increase the need for informal care of the sick and disabled. At the same time, high rates of divorce, a retreat from marriage, and increasing participation of women in the labor force are likely to decrease the ability of families to provide care. This research uses data from the National Survey of Families and Households to examine the role that friends play in the provision of care. The authors find that among caregivers, women providing care to a friend are more likely to be age peers and less likely to be employed or married than family caregivers. Friends seem less likely than family to take on care responsibilities when those responsibilities may conflict with other roles. If friends are to become a greater part of the care network, policies that encourage and enable the participation of nonfamily members will be important.

Background. As the population ages, a greater demand for long-term care services and, in particular, nursing homes is expected. Policy analysts continue to search for alternative, less costly forms of care for the elderly and have attempted to develop programs to delay or prevent nursing-home entry. Health care administrators require information for planning the future demand for nursing-home services. This study assesses the relative importance of predisposing, enabling, and need characteristics in predicting and understanding nursing-home entry. Methods. Proportional hazard models, incorporating changes in needs over time, are used to estimate the hazard of nursing-home entry over a 5-year period, using health and sociodemographic characteristics of a representative sample of elderly residents from Manitoba, Canada. Results. After age, need factors have the greatest impact on nursing-home entry. Specific medical conditions have at least as great a contribution as functional limitations. The presence of a spouse significantly reduces the hazard of entry for males only. Conclusions. The results suggest that the greatest gains in preventing or delaying nursing-home entry can be achieved through intervention programs targeted at specific medical conditions such as Alzheimer's disease, musculoskeletal disorders, and stroke.

Care-giving as an act of decision-making, as a reciprocal action, and based on sex of the care-giver, are reviewed. It is suggested that the care of elderly parents, a long-term commitment, should be viewed from a developmental perspective, beginning from childhood for an adult care-giver to be better adjusted to this role and for better outcomes.

It has been argued that without some system in which future generations of users are able to pay for their care the cost of services for an increasingly large group of older people will be borne by a declining base of economically active younger people. Is the answer a user pays approach to the financing of aged care, as promoted by recent changes to aged care financing? This paper reviews this concept and its recent history in Australia. On the basis of a brief review of alternative funding systems, it also considers the potential of public and private insurance schemes to increase funding by potential service users and underwrite the long-term viability of funding for aged care services.

On Lok Senior Health Services of San Francisco has served as a model for such programs throughout the country. This program transports disabled elderly patients to a day care center for health and supportive services and returns them to their homes at night. This allows them to avoid being placed in a nursing home and allows their caregivers to keep their day jobs. The Program of All-Inclusive Care for the Elderly (PACE) was modeled on this program and there are now 24 PACE sites throughout the US. Whether these programs can be extended to all disabled elderly Americans remains to be seen.

Advances in modern technology have resulted in increasing health care options. Unfortunately, many adults do not think about health and end-of-life decisions until they are faced with a health crisis or long-term care issues. The lack of planning has left many families devastated and overwhelmed by the decisions they face on behalf of their loved ones. Social workers and other professionals are observing family members who are ill-prepared for the decisions they have to make and the roles that they undertake as a result of the failing health of an older relative. The Advance Elder Care Family Planning model (AECFP) is designed to empower families before they face these problems.

Hierarchical modeling was employed to explore correlates of the quality of care provided in long-term care facilities. For this purpose, a multilevel analysis offers two advantages over traditional analytical approaches. First, it accounts for the correlated nature of data recorded on multiple residents from the same facility. Second, it enables the investigators to study the influence of both resident and facility characteristics on care quality. The analysis was performed on data from 301 residents randomly sampled from 88 facilities located in the Province of Quebec, Canada. Results revealed that the presence of cognitive deficits was the strongest correlate of the quality of care provided to a resident. However, this relationship was found to vary significantly across facilities. Four facility-level variables were found to influence the relationship between cognitive functioning and care quality: the number of external collaborators the facility has, the type of training the facility manager has, the size of the facility, and the age distribution of its clientele. From these results, we suggest means to improve the quality of care provided to cognitively impaired older adults living in long-term care facilities.

Using a feminist perspective, this article examines women's experiences in caring for older family members with chronic illnesses or disabilities. Central to this analysis are the concepts of the social construction of gender-based inequities in caring, the interconnections between generations of women as givers and receivers of care, and variations in family care by gender, race, ethnicity, social class and sexual orientation. The authors critique current practice interventions and policies and purpose models for the elimination of gender-based inequities in caregiving and the provision of caregiver choice and empowerment for women and men, including feminist models of practice with women caregivers and economic and long-term care supports. Keywords. Feminism, family caregiving, elder care, community-based care, long-term policy

Objectives. This study examines similarities and differences in social interactions of residents of an assisted living facility and those of a nursing home. Given increasingly popular alternative models of long-term care such as assisted living, the study seeks to identify how these long-term care settings differentially promote dependence and independence among their residents. Methods. Data were collected during 256 observations of 64 residents and their social partners at meal times in public areas. Sequences of antecedent and response behaviors relating to independence and dependence in the two different long-term care settings were examined. Results. Social partners responded consistently to behavior of long-term care residents, and the behavior of residents was consistently affected by that of their social partners. These sequential interactions were not affected by setting. Discussion. Differences in the nursing home and assisted living facilities' stated philosophies of care were not manifested in the interactions of their staff and residents.

There has been a development in understanding the lives of the elderly who have been changed by their poor health conditions that prevent them from performing their usual activities. Many people have come to understand the challenges that the elderly are experiencing such as the loss of income resources and disabilities. These lead to an assessment of the effectiveness of the services designed to improve the quality of their lives and raise concepts of a long-term health care.

This article presents a comparative analysis of the level of awareness and utilization of 15 community-based long-term care services by 213 elderly Korean and 201 non-Hispanic White Americans. We found extremely low levels of awareness and utilization of long-term health and social services among Korean Americans, in both absolute and relative terms. This finding challenges the success of the Older Americans Act, an important funding source of those services, in meeting its stated objectives to increase service availability and delivery to minority elders and socioeconomically disadvantaged elders. Strategies for effective outreach and public education efforts are also discussed. Key Words: Koreans, Non-Hispanic Whites, Long-term care, Service awareness, Utilization

Psychologists in Long-Term Care (PLTC), a national network established in 1983, has developed, with input from colleagues and consumers, standards for psychological practice in long-term care facilities. These standards address provider characteristics, methods of referral, assessment practices, treatment, and ethical issues. This article describes the document's development and offers suggestions for its use.

A number of key trends are emerging in long-term care related to financing, new models of service delivery, and shifts in consumer expectations and preferences. Taken together, changes occurring in these areas point to a rapidly transforming long-term care landscape. Financing responsibility is shifting away from the federal government to states, individuals, and their families; providers are integrating and managing acute and long-term care services and adding new services to the continuum of care; and consumers are thinking more seriously about how to plan and pay for their future care needs, as well as how to independently navigate the long-term care system. Key Words: Assisted living, Subacute care, Long-term care insurance, Consumer-directed care, PACE, SHMO

Widely studied as a predictor of long-term care use, functional disability is also an important explanatory variable for acute care costs spent for the elderly. As policy makers contemplate ways to control rapidly growing Medicare expenditures, such as increasing the enrollment of beneficiaries into managed care programs, knowledge about the relation between functional disability and Medicare costs is likely to become more important for the design of program features. The research described here uses data from the new Medicare Current Beneficiary Survey to estimate the relation between functional disability and Medicare costs, the effects on costs of interactions between disability and other personal characteristics of beneficiaries, and changes in the level of disability and Medicare costs.

This article describes the development and implementation of a brief values assessment protocol to be used by case managers working in community-based long-term care (LTC) for the elderly and presents data on the values and preferences of 790 LTC clients at two locations. The importance that clients placed on selected issues related to their care (e.g., privacy, daily routines, activities, involvement of family in care, the trade-off between freedom and safety) varied as did the specific content of those issues. Associations were found between the content and strength of preferences. The work has implications for research and practice. Key Words: Case management, Home and community-based services, Assessment, Values, Preferences

In 1990, Great Britain enacted the National Health Service and Community Care Act to reduce unnecessary institutionalization, improve coordination of community-based long-term care, and stimulate private service provision. An overview of four major principles of the legislation is provided: the elevation of the assessor/care manager role, the emphasis on inter-agency collaboration across the health and social care divide, privatization of service, and support of carers (caregivers). Preliminary findings related to their implementation indicate incremental rather than sweeping change. The elements of the new policy that borrow from American models of community care - and may be difficult to transplant - are highlighted. Key Words: Community care, Long-term care, Institutionalization, Nursing homes, Great Britain

The authors review the literature on ethnic minority caregivers and suggest that ethnicity and culture play a significant role in the stress and coping process for Latino caregivers. Caregivers of older Latinos face special challenges in the caregiving for individuals at higher risk for specific chronic diseases, who are disabled at earlier ages, and who have more functional disabilities. Ethnicity and culture can also influence the appraisal of stress events, the perception and use of family support, and coping behaviors. Socioeconomic class and minority group status are discussed as additional sources of variation in the caregiver stress and coping model. Key Words: Culture, Caregiving, Stress and coping, Latinos, Hispanics, Social support

Community elders (N = 330) were interviewed by telephone twice at baseline using both computer-assisted telephone interviews (CATI) and nurse clinicians, and at four-month follow-up using CATI to collect alternative paraprofessional home care adequacy measures. Measurement format influenced both reliability and observed levels of adequacy but alternative adequacy measures converged and were not closely linked to functional status. The predictive validity of measures based on clinical standards with respect to health outcomes was also demonstrated. These findings support emerging approaches in primary care and home health quality measurement that consider multiple dimensions of user response to formal and informal care. Key Words: Long-term care, Quality, Outcomes, Consumer satisfaction

Public long-term-care insurance should be developed to answer the growing medical needs of the elderly. However, launching a social-insurance program for long-term care and getting rid of the means-testing required by Medicaid would create legitimate cost issues. It is also feared that the introduction of a public long-term-care insurance would increase improper demand for formal services and reduce informal caregiving by family members.

Background. Past studies have emphasized that patients with pressure ulcers are at high risk of dying. However, it remains unclear whether this increased risk is related to the ulcer or to coexisting conditions. In this study we examined the independent effect of pressure ulcers on the survival of long-term care residents. Methods. We evaluated all 19,981 long-term care residents institutionalized in Department of Veterans Affairs (VA) long-term care facilities as of April 1, 1993. Baseline resident characteristics and survival status were obtained by merging data from five existing VA data bases. Survival experience over a 6-month period was described using a proportional hazards model. Results. Pressure ulcers were present in 1,539 (7.7%) long-term care residents. Residents with pressure ulcers had a relative risk of 2.37 (95% CI = 2.13, 2.64) for dying as compared to those without ulcers. After adjusting for 16 other measures of clinical and functional status, the relative risk associated with pressure ulcers decreased to 1.45 (95% CI = 1.30, 1.65). No increased risk of death was noted for residents with deeper ulcers. Conclusions. Pressure ulcers are a significant marker for long-term care residents at risk of dying. After adjusting for clinical and functional status, however, the independent risk associated with pressure ulcers declines considerably. The fact that larger ulcers are not associated with greater risk suggests that other unmeasured clinical conditions may also be contributing to the increased mortality associated with pressure ulcers.

Long-term care (LTC) in institutions is one of the last major remaining gaps in the social insurance safety net provided to beneficiaries of Social Security. However, Medicaid pays almost half of the costs of nursing home care after institutionalized elderly or disabled persons become impoverished. Structural reasons make it impossible for private insurance to cover institutional LTC for the bulk of the elderly and disabled. The paper demonstrates that there is an efficient, equitable and feasible social insurance solution to this serious social problem. The second section details a plan for a Medicare Part C Trust Fund to cover extended stays in nursing homes by Social Security beneficiaries (virtually the entire elderly population and most of the long-term disabled). It involves: (1) maintenance of current government funding indexed to inflation; (2) a premium taken from the cost-of-living allowances (COLAs) due to beneficiaries in the years immediately after they qualify for Social Security; (3) a substantial copayment; (4) a deductible consisting of the first three months of nursing home care; (5) a two-year waiting period between qualification for Social Security and full LTC coverage. The three revenue streams will all increase automatically with inflation. The plan is designed to cover only institutional LTC costs in order to reduce complexity, minimize the price tag and maximize its political chances. However, it could be expanded to cover home and community-based care. The second half of the analysis explores the policy justifications supporting such a plan and considers the political reasons why this carefully crafted proposal might appeal to moderate conservatives as well as to progressives.