540049 research-article2014
JAGXXX10.1177/0733464814540049Journal of Applied GerontologyCastle and Resnick
Article
Service-Enriched Housing: The Staying at Home Program
Journal of Applied Gerontology 1–21 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464814540049 jag.sagepub.com
Nicholas Castle1 and Neil Resnick1
Abstract Introduction: The purpose of this research was to determine whether service-enriched housing (i.e., the Staying at Home [SAH] program) in publicly subsidized buildings for low-income older adults influenced resident outcomes. Method: Eleven elderly high-rise buildings were used. Seven buildings had the SAH program and four did not. Information was collected from resident questionnaires, housing managers data, and medical information. A total of 10 desired outcomes were proposed as part of SAH (e.g., health improvements, receive more non-institutional services, receive more preventive services, and be less likely to be institutionalized). Information was collected over the course of the SAH program every 6 months from December 2008 through June 2011. Results: Overall, 736 surveys were completed by SAH program participants and 399 were completed by control group participants. Seven of the ten desired outcomes were achieved, and in 3 of the ten cases, no differences between the SAH group and control group were identified. The program was also beneficial with respect to cost savings. Conclusion: On the basis of these findings, the SAH program should be viewed as a success. In this case, service-enriched housing for elders in high-rise buildings would appear to be beneficial. Keywords high-rise, services, aging-in-place Manuscript received: August 21, 2013; final revision received: April 9, 2014; accepted: May 25, 2014. 1University
of Pittsburgh, PA, USA
Corresponding Author: Nicholas Castle, University of Pittsburgh, A610 Crabtree Hall, Pittsburgh, PA 15261, USA. Email: [email protected]
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Journal of Applied Gerontology
The purpose of this research was to determine whether enhanced services provided to elders (i.e., what has become known as service-enriched housing) in publicly subsidized buildings for low-income older adults subsequently improved resident outcomes. Outcomes examined include nursing home placement and/or high use of medical services such as emergency room (ER) use. The enhanced services provided were for clients as part of a program called Staying at Home (SAH). Service-enriched housing has been defined as “Living arrangements that provide health and/or social services in an accessible, supportive environment” (Pynoos, Liebig, Alley, & Nishita, 2005a, p. 2). However, in many ways this model of supportive housing is a reinvention of services that have existed for many decades provided under a variety of titles (Housing Plus Services Committee, 2004a). These models have multiple meanings and overlapping definitions (Cohen, Mulroy, Tull, White, & Crowley, 2004). The Housing Plus Services Committee of the National Low Income Housing Coalition has developed a matrix analyzing several of these models (Housing Plus Services Committee, 2004b) and they appear in texts (e.g., Tull, 1999). Some older models of supportive housing services specific to elders (e.g., congregate housing) have been examined (Ruchlin & Morris, 1987). Nevertheless, little evidence exists that more recent initiatives of supportive housing services specific to elders are beneficial to providers or consumers (Castle, 2008).
Policy and Service-Enriched Housing A markedly aging population and nursing home care, paid for from state and federal coffers (primarily Medicaid), has helped push forward a long-term care agenda that emphasizes less use of relatively expensive nursing home settings and more use of less expensive in-home services (Black, Dobbs, & Young, 2012). Policy makers have promoted aging-in-place legislation (AARP, 2000) and there has been continual pressure to expand home care as a way to delay nursing home use (Kelly, Fausset, Rogers, & Fisk, 2012). For example, policies such as the Americans With Disabilities Act (ADA)/ Olmstead decision, the New Freedom Initiative, and Executive Order 13217, to increase the autonomy and quality of life for individuals, moving them away from institutional settings and into communities through the provision of housing and personal assistance services (The White House, 2001). The Patient Protection and Affordable Care Act (P.L. 111-148) has instituted new regulations to help seniors remain in their communities. States will have new options to offer home and community-based health care services through a Medicaid state plan. The Community First Choice Option in
Downloaded from jag.sagepub.com by guest on November 16, 2015
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Castle and Resnick
Medicaid will allow seniors to avoid institutional settings by providing them with community-based services (Richards, 2010). A State Balancing Incentive Program phased in until 2015 will provide financial matching to states that offer “non-institutionally-based long-term care services.” Medicare Part D will also provide cost sharing benefits to those receiving care at home equal to those receiving care in an institutional setting. Overall, the reforms are intended to decrease the number of barriers to receiving home- and community-based services (HCBS; Wiener, Tilly, & Alecxih, 2002). However, evidence is needed that HCBS promoting service-enriched housing models are beneficial (Castle, 2008; Lehning, Smith, & Dunkle, 2013).
Elders in High-Rise Buildings The SAH program was implemented in publicly subsidized housing for lowincome older adults. Specifically, elderly high-rise communities were targeted. Elderly high-rise communities are buildings with 20 or more units offering subsidized housing to older persons. An estimated 1.2 million older persons live in these settings in the United States (http://portal.hud.gov/portal/page/portal/HUD). A total of 3,300 housing agencies manage these sites, most of which house low-income residents. Elderly high-rise communities are an important component of aging-in-place policies; yet, little is known about the services that need to be provided in these settings. There are a wide range of services provided at these sites. Many residents receive no services beyond whatever their health insurance covers or seek it outside the system. In other cases, service-enriched housing programs link residents to services and may become sites for programs such as meals. Beginning in 1993, Section 202 housing complexes with a significant percentage of frail older persons have been able to hire coordinators to link residents with services. In 1999, at least 30% of all Section 202 facilities reported having a service coordinator on staff, and 40% reported the availability of a service coordinator within the community (Pynoos, Liebig, Alley, & Nishita, 2005b). Favorable outcomes of service-enriched programs are noted in the literature (e.g., Feldman, Latimer, & Davidson, 1996). Evaluations have been conducted of the Congregate Housing Services Program (CHSP) and the Supportive Services Program in Senior Housing (SSPSH) demonstration. The CHSP was created by United States Department of Housing and Urban Development (HUD)to create service-enriched housing for frail elderly residents of Section 202 and public housing (see Golant, 2003). Through CHSP, sites provided a variety of services including “meals, transportation, homemaking, shopping and service coordination” (Pynoos et al.,
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2005b, p. 16). Evaluations of CHSP have found that many residents could not have remained in their residences without the provision of CHSP services (Research Triangle Institute, 1996; Sherwood et al., 1985). The SSPSH demonstration project created through the Robert Wood Johnson Foundation (RWJF) provided “incentives to state Housing Finance Agencies (HFA) to use their excess reserves for implementing services in housing funded through HFA low-interest loans” (Pynoos et al., 2005b, p. 17). Unlike CHSP services, SSPSH services were market driven upon assessment of residents’ willingness to pay for services. Evaluations of SSPSH services revealed that service coordinators were able to leverage resources that resulted in services needed by residents (Feder, Scanlon, & Howard, 1992). CHSP and SSPSH are often referred to as large-scale demonstration projects in this area. They are often noted in the literature. Several more recent smaller demonstration projects are described in an Assistant Secretary for Planning and Evaluation (ASPE ;2012) report of service-enriched programs.
Conceptual Framework The conceptual framework guiding this study was modified from the framework initially developed by Marek and associates (2005). The conceptual framework helps understand the relationships between the provision of service-enriched housing and the outcomes examined and is shown in Figure 1. The conceptual framework is an amalgam of concepts drawn from Donabedian (1978) and the Medical Outcomes Study framework (Marek et al., 2005). Donabedian has analyzed the quality of health care organizations in terms of three components: structures, processes, and outcomes (SPO; Donabedian, 1978). Structures are defined as the conditions under which care is provided, which in this study refer to the characteristics of residents. Processes include the activities that are carried out to provide care, which in this case encompass the service-enriched services. Outcomes are results or changes that can be attributed to the care. Outcomes that are specific to the service-enriched include better medication management are used described in more detail below. In our representation of this conceptual framework (i.e., Figure 1), we also include the hypothesized influence of the SAH program indicated by a positive or minus sign for specific outcomes. This is based on the notion that specific components of the SAH program will likely influence specific outcomes. In addition, the outcomes are separated into proximal and distal. This recognizes that some outcomes are influenced by service-enriched services and in some instances also by each other. That is, the proximal outcomes are likely
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Castle and Resnick Structure
Process
Outcome (proximal)
Outcome (distal)
Service-Enriched Services Health Service Ulizaon (+) Care Coordinaon
Client Characteriscs
Instuonalized (-)
Health Improvements (+) Non-Instuonal Services (+) Preventave Service Use (+)
Age Gender Race
Living Arrangement
Advance Planning
Advanced Planning Use (+)
Medicaon Management
Health Improvements (+)
Health Status ER Visits (-)
Health Care Diary / Outreach
Unplanned Hospitalizaons (-)
Engaged in Own Care (+) Preventave Service Use (+) Quality of life (+) Sasfacon with Services (+)
Figure 1. Evaluation framework for the Staying at Home Program.
Note. The (−) and (+) follow the proposed hypotheses of the Staying at Home Program. For example, Health Services Utilization will be greater for the program participants (+) compared with the control group.
more influenced by service-enriched provisions, whereas the distal outcomes are influenced by a mix of service-enriched services and proximal outcomes.
SAH Program Overview In this initiative, 11 elderly high-rise buildings in the Pittsburgh areawere used. Seven buildings had the SAH program and 4 did not. The approximate number of residents in the seven SAH buildings was 330 and in the 4 nonSAH buildings totaled 220. The residents lived in similar neighborhoods and were provided with few other services. Moreover, as described below, the demographic characteristics of the residents in the 7 SAH buildings were similar to those in the 4 non-SAH buildings. The enhanced services provided as part of the SAH program included four basic components: Care Coordination, Advance Planning, Medication Management, and a Health Care Diary. These services were provided by an intervention team consisting of a social worker and a registered nurse employed by a local health care provider. In addition, a Medical Director was available for specific consultations. The services were available to all residents in the SAH buildings, and the local health care provider paid for all the services provided.
Care Coordination Each case was managed by a care coordinator (i.e., a social worker) who developed a plan jointly with the client. Examples of activities in care coordination included coordinating physician visits, coordinating care with other
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Journal of Applied Gerontology
health care providers, encouraging the client’s to seek preventive care, connecting the client with needed community support services, and helping with transitions of care. Given these enhanced services of care coordination provided as part of the SAH program, it was hypothesized that the intervention group would utilize more services (Hypothesis 1 [H1]), experience health improvements (Hypothesis 2 [H2]), receive more non-institutional services (Hypothesis 3 [H3]), receive more preventive services (Hypothesis 4 [H4]), and be less likely to be institutionalized (Hypothesis 5 [H5]) than the control group. These potential outcomes of the SAH program are shown in Table 1 and Figure 1.
Advance Planning Care coordinators helped clients with advance directives; planning for housing needs (placement, if needed); and money management (referrals to appropriate agencies). Given these enhanced services of advance planning provided as part of the SAH program, it was hypothesized that the intervention group would be more likely to have considered an advance directive (Hypothesis 6 [H6] shown in Table 1 and Figure 1).
Medication Management There were two levels of medication management offered. The first level involved the care coordinator in updating the medication list in the health care diary (see below), reviewing the list with SAH program clinical coordinator and/or the medical director, and assisting with refills. The second level was offered by a registered nurse who assisted with filling the pill boxes, injections, and medication reconciliation at the time of transition of care. Given these enhanced services of medication management provided as part of the SAH program, it was hypothesized that the intervention group would experience health improvements (H2), and have fewer ER visits and unplanned hospitalizations (Hypothesis 7 [H7] shown in Table 1 and Figure 1).
Health Care Diary/Outreach Clients received assistance in maintaining a health care diary that contained critical health care information. Each client was encouraged to maintain the diary, although the diary was also routinely updated by the care coordinator and the clients’ health care providers. Key pieces of information such as
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7
Castle and Resnick Table 1. Proposed Outcomes of the Staying at Home Program. Enhanced services
Content of service
Proposed outcome
Measure
Care coordination
Engage client in health promoting activities
Health care utilization questionnaire
Care coordination
Engage client in health promoting activities
Intervention group will utilize more services (H1) Intervention group will show more health improvements (H2)
Care coordination
Care coordinator will help with clients’ care
Care coordination
Blood pressure checks and sessions on health-related topics All of the above for care coordination
Care coordination
Advance planning
Help with advance directives and future planning
Medication management
Assistance with medication management
Medication management
Assistance with medication management
Health Care Diary/outreach
Engage client in their own health care
Health care diary/ outreach
Health care diary/ outreach
Improve communication with the health care providers Engage client in their own health care
Health care diary/ outreach
Engage client in their own health care
Intervention group will receive more noninstitutional services (H3) Intervention group will receive more preventive services (H4) Intervention group will be less likely to be institutionalized (H5) Intervention group will be more likely to have considered an advance directive (H6) Intervention group will show more health improvements (H2)
Intervention group will have less ER visits and unplanned hospitalizations (H7) Intervention group will be more engaged in own care (H8) Intervention group will receive more preventive services (H4) Intervention group will have a high quality of life (H9) Intervention group will be satisfied with services (H10)
Questionnaire items: a. Short Form 12 b. Depression screen c. Health conditions d. Social contact e. Activities of daily living Services received inventory
10 key questionnaire
Discharge questionnaire
Advance planning questionnaire
Questionnaire items: a. Short Form 12 b. Depression screen c. Health conditions d. Social contact e. Activities of daily living Health utilization questionnaire
Health utilization questionnaire Health utilization questionnaire
Quality of life questionnaire
Satisfaction questionnaire
when immunizations were received were included. The diary served two purposes: (a) engage the client in their own health care and (b) improve communication with the clients’ health care providers.
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Journal of Applied Gerontology
The SAH program also offered health care outreach to all residents at the participating high rises. The SAH outreach nurse visited monthly to provide residents with blood pressure checks and health-related educational sessions. The education sessions varied monthly and included topic such as managing diabetes and high blood pressure. Given these enhanced services of the health care diary and outreach provided as part of the SAH program, it was hypothesized that the intervention group would be more engaged in one’s own care (H8), receive more preventive services (H4), have an improved quality of life (H9), and be satisfied with the provided services (Hypothesis 10 [H10]). These potential outcomes of the SAH program are shown in Table 1 and Figure 1.
Method Overview Information was collected over the course of the SAH program from December 2008 through June 2011 involving an experimental and control group of residents/facilities. The research used a pre–post format. The information collected consisted of resident questionnaires (e.g., self-rated health), housing managers data (e.g., transfers from the high rise), and medical information (e.g., medical records). All residents at the11 high-rise buildings were eligible to participate in the study. Prior to data collection, the study was presented in a series of flyers and building manager presentations at a series of large group resident meetings. The control sites were selected by the research team to be in close proximity to the intervention sites. These sites were not providing service-enriched services and had similar resident characteristics (e.g., age and income) to those in the experimental group. The project was approved by The University of Pittsburgh Institutional Review Board (IRB).
Questionnaire Development The questionnaire was developed based on the proposed outcomes of the SAH program. Major sections of the questionnaire collected information on demographics, health care utilization, Short Form 12 (i.e., functional status [SF-12®]; Ware, Kosinski, & Keller, 1996), depression (i.e., Patient Health Questionnaire [PHQ-9]; Kroenke, Spitzer, & Williams, 2001), health conditions, social contact, activities (e.g., Instrumental Activities of Daily Living [IADLs]; Lawton & Brody, 1969), Advance Planning (e.g., Willingness to Accept Life-Sustaining Treatment instrument [WALT]; Fried, Bradley, &
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Castle and Resnick
Towle, 2002), 10 keys to healthy aging (i.e., use of preventive services [10 Keys™]; Center for Aging and Population Health, 2012), satisfaction and quality of life (e.g., Geriatric Quality of Life Questionnaire [GQLQ]; Guyatt et al., 1993). The complete questionnaire is available from the authors. Interviews with 10 elderly high-rise residents were used to further refine the questionnaire. This testing (cognitive interviewing) is used to help determine whether potential respondents consider a question to be unclear, so that wording of items can be refined (Levine, Fowler, & Brown, 2005). Minor wording changes were made as a result of this cognitive interviewing process.
Data Collection The questionnaires were administered in person. A gift card was used as an incentive to complete the questionnaire (US$10) for both SAH program participants and control group participants. This process was conducted every 6 months over the course of 3 years. Residents were encouraged to participate by building managers, building care coordinators, and the outreach nurse. Each month the data were collected from building managers at the participating high rises on the number of move-ins, move-outs, deaths, and nursing home transfers. The building sites were in very close proximity to a single large integrated health care provider network. Health care utilization data were available for residents (including ER visits, admissions, and outpatient hospital visits) from the provider. Informed consent was given by most residents (i.e., 96%) to view the health care utilization records.
Statistical Approach Identical questionnaires were used at sites receiving enhanced services and those not receiving enhanced services. Chi-square tests were used to determine differences between the groups. Findings are presented comparing prewith post-information in the enhanced group and the control group using the resident data collected. The resident information was collected over six consecutive periods and participation varied in each period. For the enhanced group, participation increased over time from 78 residents to 148 residents. This increase in participation probably reflected greater acceptance of the SAH program. Thus, for both groups some different residents were included in each time period, and different residents had varying degrees of participation in the program. In the analyses presented, the resident responses from December 2008 to June 2009 are combined. These residents had the most exposure to the SAH program. The
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Journal of Applied Gerontology
mean scores of these residents from December 2008 to June 2009 are compared with those of the same residents in June 2011. Thus, scores from 104 residents in the enhanced group are compared with 72 in the control group. One limitation of this analytic approach is right censoring (e.g., residents dropping out due to illness or death). Very few residents were subject to this censoring (
JAGXXX10.1177/0733464814540049Journal of Applied GerontologyCastle and Resnick
Article
Service-Enriched Housing: The Staying at Home Program
Journal of Applied Gerontology 1–21 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464814540049 jag.sagepub.com
Nicholas Castle1 and Neil Resnick1
Abstract Introduction: The purpose of this research was to determine whether service-enriched housing (i.e., the Staying at Home [SAH] program) in publicly subsidized buildings for low-income older adults influenced resident outcomes. Method: Eleven elderly high-rise buildings were used. Seven buildings had the SAH program and four did not. Information was collected from resident questionnaires, housing managers data, and medical information. A total of 10 desired outcomes were proposed as part of SAH (e.g., health improvements, receive more non-institutional services, receive more preventive services, and be less likely to be institutionalized). Information was collected over the course of the SAH program every 6 months from December 2008 through June 2011. Results: Overall, 736 surveys were completed by SAH program participants and 399 were completed by control group participants. Seven of the ten desired outcomes were achieved, and in 3 of the ten cases, no differences between the SAH group and control group were identified. The program was also beneficial with respect to cost savings. Conclusion: On the basis of these findings, the SAH program should be viewed as a success. In this case, service-enriched housing for elders in high-rise buildings would appear to be beneficial. Keywords high-rise, services, aging-in-place Manuscript received: August 21, 2013; final revision received: April 9, 2014; accepted: May 25, 2014. 1University
of Pittsburgh, PA, USA
Corresponding Author: Nicholas Castle, University of Pittsburgh, A610 Crabtree Hall, Pittsburgh, PA 15261, USA. Email: [email protected]
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Journal of Applied Gerontology
The purpose of this research was to determine whether enhanced services provided to elders (i.e., what has become known as service-enriched housing) in publicly subsidized buildings for low-income older adults subsequently improved resident outcomes. Outcomes examined include nursing home placement and/or high use of medical services such as emergency room (ER) use. The enhanced services provided were for clients as part of a program called Staying at Home (SAH). Service-enriched housing has been defined as “Living arrangements that provide health and/or social services in an accessible, supportive environment” (Pynoos, Liebig, Alley, & Nishita, 2005a, p. 2). However, in many ways this model of supportive housing is a reinvention of services that have existed for many decades provided under a variety of titles (Housing Plus Services Committee, 2004a). These models have multiple meanings and overlapping definitions (Cohen, Mulroy, Tull, White, & Crowley, 2004). The Housing Plus Services Committee of the National Low Income Housing Coalition has developed a matrix analyzing several of these models (Housing Plus Services Committee, 2004b) and they appear in texts (e.g., Tull, 1999). Some older models of supportive housing services specific to elders (e.g., congregate housing) have been examined (Ruchlin & Morris, 1987). Nevertheless, little evidence exists that more recent initiatives of supportive housing services specific to elders are beneficial to providers or consumers (Castle, 2008).
Policy and Service-Enriched Housing A markedly aging population and nursing home care, paid for from state and federal coffers (primarily Medicaid), has helped push forward a long-term care agenda that emphasizes less use of relatively expensive nursing home settings and more use of less expensive in-home services (Black, Dobbs, & Young, 2012). Policy makers have promoted aging-in-place legislation (AARP, 2000) and there has been continual pressure to expand home care as a way to delay nursing home use (Kelly, Fausset, Rogers, & Fisk, 2012). For example, policies such as the Americans With Disabilities Act (ADA)/ Olmstead decision, the New Freedom Initiative, and Executive Order 13217, to increase the autonomy and quality of life for individuals, moving them away from institutional settings and into communities through the provision of housing and personal assistance services (The White House, 2001). The Patient Protection and Affordable Care Act (P.L. 111-148) has instituted new regulations to help seniors remain in their communities. States will have new options to offer home and community-based health care services through a Medicaid state plan. The Community First Choice Option in
Downloaded from jag.sagepub.com by guest on November 16, 2015
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Castle and Resnick
Medicaid will allow seniors to avoid institutional settings by providing them with community-based services (Richards, 2010). A State Balancing Incentive Program phased in until 2015 will provide financial matching to states that offer “non-institutionally-based long-term care services.” Medicare Part D will also provide cost sharing benefits to those receiving care at home equal to those receiving care in an institutional setting. Overall, the reforms are intended to decrease the number of barriers to receiving home- and community-based services (HCBS; Wiener, Tilly, & Alecxih, 2002). However, evidence is needed that HCBS promoting service-enriched housing models are beneficial (Castle, 2008; Lehning, Smith, & Dunkle, 2013).
Elders in High-Rise Buildings The SAH program was implemented in publicly subsidized housing for lowincome older adults. Specifically, elderly high-rise communities were targeted. Elderly high-rise communities are buildings with 20 or more units offering subsidized housing to older persons. An estimated 1.2 million older persons live in these settings in the United States (http://portal.hud.gov/portal/page/portal/HUD). A total of 3,300 housing agencies manage these sites, most of which house low-income residents. Elderly high-rise communities are an important component of aging-in-place policies; yet, little is known about the services that need to be provided in these settings. There are a wide range of services provided at these sites. Many residents receive no services beyond whatever their health insurance covers or seek it outside the system. In other cases, service-enriched housing programs link residents to services and may become sites for programs such as meals. Beginning in 1993, Section 202 housing complexes with a significant percentage of frail older persons have been able to hire coordinators to link residents with services. In 1999, at least 30% of all Section 202 facilities reported having a service coordinator on staff, and 40% reported the availability of a service coordinator within the community (Pynoos, Liebig, Alley, & Nishita, 2005b). Favorable outcomes of service-enriched programs are noted in the literature (e.g., Feldman, Latimer, & Davidson, 1996). Evaluations have been conducted of the Congregate Housing Services Program (CHSP) and the Supportive Services Program in Senior Housing (SSPSH) demonstration. The CHSP was created by United States Department of Housing and Urban Development (HUD)to create service-enriched housing for frail elderly residents of Section 202 and public housing (see Golant, 2003). Through CHSP, sites provided a variety of services including “meals, transportation, homemaking, shopping and service coordination” (Pynoos et al.,
Downloaded from jag.sagepub.com by guest on November 16, 2015
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Journal of Applied Gerontology
2005b, p. 16). Evaluations of CHSP have found that many residents could not have remained in their residences without the provision of CHSP services (Research Triangle Institute, 1996; Sherwood et al., 1985). The SSPSH demonstration project created through the Robert Wood Johnson Foundation (RWJF) provided “incentives to state Housing Finance Agencies (HFA) to use their excess reserves for implementing services in housing funded through HFA low-interest loans” (Pynoos et al., 2005b, p. 17). Unlike CHSP services, SSPSH services were market driven upon assessment of residents’ willingness to pay for services. Evaluations of SSPSH services revealed that service coordinators were able to leverage resources that resulted in services needed by residents (Feder, Scanlon, & Howard, 1992). CHSP and SSPSH are often referred to as large-scale demonstration projects in this area. They are often noted in the literature. Several more recent smaller demonstration projects are described in an Assistant Secretary for Planning and Evaluation (ASPE ;2012) report of service-enriched programs.
Conceptual Framework The conceptual framework guiding this study was modified from the framework initially developed by Marek and associates (2005). The conceptual framework helps understand the relationships between the provision of service-enriched housing and the outcomes examined and is shown in Figure 1. The conceptual framework is an amalgam of concepts drawn from Donabedian (1978) and the Medical Outcomes Study framework (Marek et al., 2005). Donabedian has analyzed the quality of health care organizations in terms of three components: structures, processes, and outcomes (SPO; Donabedian, 1978). Structures are defined as the conditions under which care is provided, which in this study refer to the characteristics of residents. Processes include the activities that are carried out to provide care, which in this case encompass the service-enriched services. Outcomes are results or changes that can be attributed to the care. Outcomes that are specific to the service-enriched include better medication management are used described in more detail below. In our representation of this conceptual framework (i.e., Figure 1), we also include the hypothesized influence of the SAH program indicated by a positive or minus sign for specific outcomes. This is based on the notion that specific components of the SAH program will likely influence specific outcomes. In addition, the outcomes are separated into proximal and distal. This recognizes that some outcomes are influenced by service-enriched services and in some instances also by each other. That is, the proximal outcomes are likely
Downloaded from jag.sagepub.com by guest on November 16, 2015
5
Castle and Resnick Structure
Process
Outcome (proximal)
Outcome (distal)
Service-Enriched Services Health Service Ulizaon (+) Care Coordinaon
Client Characteriscs
Instuonalized (-)
Health Improvements (+) Non-Instuonal Services (+) Preventave Service Use (+)
Age Gender Race
Living Arrangement
Advance Planning
Advanced Planning Use (+)
Medicaon Management
Health Improvements (+)
Health Status ER Visits (-)
Health Care Diary / Outreach
Unplanned Hospitalizaons (-)
Engaged in Own Care (+) Preventave Service Use (+) Quality of life (+) Sasfacon with Services (+)
Figure 1. Evaluation framework for the Staying at Home Program.
Note. The (−) and (+) follow the proposed hypotheses of the Staying at Home Program. For example, Health Services Utilization will be greater for the program participants (+) compared with the control group.
more influenced by service-enriched provisions, whereas the distal outcomes are influenced by a mix of service-enriched services and proximal outcomes.
SAH Program Overview In this initiative, 11 elderly high-rise buildings in the Pittsburgh areawere used. Seven buildings had the SAH program and 4 did not. The approximate number of residents in the seven SAH buildings was 330 and in the 4 nonSAH buildings totaled 220. The residents lived in similar neighborhoods and were provided with few other services. Moreover, as described below, the demographic characteristics of the residents in the 7 SAH buildings were similar to those in the 4 non-SAH buildings. The enhanced services provided as part of the SAH program included four basic components: Care Coordination, Advance Planning, Medication Management, and a Health Care Diary. These services were provided by an intervention team consisting of a social worker and a registered nurse employed by a local health care provider. In addition, a Medical Director was available for specific consultations. The services were available to all residents in the SAH buildings, and the local health care provider paid for all the services provided.
Care Coordination Each case was managed by a care coordinator (i.e., a social worker) who developed a plan jointly with the client. Examples of activities in care coordination included coordinating physician visits, coordinating care with other
Downloaded from jag.sagepub.com by guest on November 16, 2015
6
Journal of Applied Gerontology
health care providers, encouraging the client’s to seek preventive care, connecting the client with needed community support services, and helping with transitions of care. Given these enhanced services of care coordination provided as part of the SAH program, it was hypothesized that the intervention group would utilize more services (Hypothesis 1 [H1]), experience health improvements (Hypothesis 2 [H2]), receive more non-institutional services (Hypothesis 3 [H3]), receive more preventive services (Hypothesis 4 [H4]), and be less likely to be institutionalized (Hypothesis 5 [H5]) than the control group. These potential outcomes of the SAH program are shown in Table 1 and Figure 1.
Advance Planning Care coordinators helped clients with advance directives; planning for housing needs (placement, if needed); and money management (referrals to appropriate agencies). Given these enhanced services of advance planning provided as part of the SAH program, it was hypothesized that the intervention group would be more likely to have considered an advance directive (Hypothesis 6 [H6] shown in Table 1 and Figure 1).
Medication Management There were two levels of medication management offered. The first level involved the care coordinator in updating the medication list in the health care diary (see below), reviewing the list with SAH program clinical coordinator and/or the medical director, and assisting with refills. The second level was offered by a registered nurse who assisted with filling the pill boxes, injections, and medication reconciliation at the time of transition of care. Given these enhanced services of medication management provided as part of the SAH program, it was hypothesized that the intervention group would experience health improvements (H2), and have fewer ER visits and unplanned hospitalizations (Hypothesis 7 [H7] shown in Table 1 and Figure 1).
Health Care Diary/Outreach Clients received assistance in maintaining a health care diary that contained critical health care information. Each client was encouraged to maintain the diary, although the diary was also routinely updated by the care coordinator and the clients’ health care providers. Key pieces of information such as
Downloaded from jag.sagepub.com by guest on November 16, 2015
7
Castle and Resnick Table 1. Proposed Outcomes of the Staying at Home Program. Enhanced services
Content of service
Proposed outcome
Measure
Care coordination
Engage client in health promoting activities
Health care utilization questionnaire
Care coordination
Engage client in health promoting activities
Intervention group will utilize more services (H1) Intervention group will show more health improvements (H2)
Care coordination
Care coordinator will help with clients’ care
Care coordination
Blood pressure checks and sessions on health-related topics All of the above for care coordination
Care coordination
Advance planning
Help with advance directives and future planning
Medication management
Assistance with medication management
Medication management
Assistance with medication management
Health Care Diary/outreach
Engage client in their own health care
Health care diary/ outreach
Health care diary/ outreach
Improve communication with the health care providers Engage client in their own health care
Health care diary/ outreach
Engage client in their own health care
Intervention group will receive more noninstitutional services (H3) Intervention group will receive more preventive services (H4) Intervention group will be less likely to be institutionalized (H5) Intervention group will be more likely to have considered an advance directive (H6) Intervention group will show more health improvements (H2)
Intervention group will have less ER visits and unplanned hospitalizations (H7) Intervention group will be more engaged in own care (H8) Intervention group will receive more preventive services (H4) Intervention group will have a high quality of life (H9) Intervention group will be satisfied with services (H10)
Questionnaire items: a. Short Form 12 b. Depression screen c. Health conditions d. Social contact e. Activities of daily living Services received inventory
10 key questionnaire
Discharge questionnaire
Advance planning questionnaire
Questionnaire items: a. Short Form 12 b. Depression screen c. Health conditions d. Social contact e. Activities of daily living Health utilization questionnaire
Health utilization questionnaire Health utilization questionnaire
Quality of life questionnaire
Satisfaction questionnaire
when immunizations were received were included. The diary served two purposes: (a) engage the client in their own health care and (b) improve communication with the clients’ health care providers.
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The SAH program also offered health care outreach to all residents at the participating high rises. The SAH outreach nurse visited monthly to provide residents with blood pressure checks and health-related educational sessions. The education sessions varied monthly and included topic such as managing diabetes and high blood pressure. Given these enhanced services of the health care diary and outreach provided as part of the SAH program, it was hypothesized that the intervention group would be more engaged in one’s own care (H8), receive more preventive services (H4), have an improved quality of life (H9), and be satisfied with the provided services (Hypothesis 10 [H10]). These potential outcomes of the SAH program are shown in Table 1 and Figure 1.
Method Overview Information was collected over the course of the SAH program from December 2008 through June 2011 involving an experimental and control group of residents/facilities. The research used a pre–post format. The information collected consisted of resident questionnaires (e.g., self-rated health), housing managers data (e.g., transfers from the high rise), and medical information (e.g., medical records). All residents at the11 high-rise buildings were eligible to participate in the study. Prior to data collection, the study was presented in a series of flyers and building manager presentations at a series of large group resident meetings. The control sites were selected by the research team to be in close proximity to the intervention sites. These sites were not providing service-enriched services and had similar resident characteristics (e.g., age and income) to those in the experimental group. The project was approved by The University of Pittsburgh Institutional Review Board (IRB).
Questionnaire Development The questionnaire was developed based on the proposed outcomes of the SAH program. Major sections of the questionnaire collected information on demographics, health care utilization, Short Form 12 (i.e., functional status [SF-12®]; Ware, Kosinski, & Keller, 1996), depression (i.e., Patient Health Questionnaire [PHQ-9]; Kroenke, Spitzer, & Williams, 2001), health conditions, social contact, activities (e.g., Instrumental Activities of Daily Living [IADLs]; Lawton & Brody, 1969), Advance Planning (e.g., Willingness to Accept Life-Sustaining Treatment instrument [WALT]; Fried, Bradley, &
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Towle, 2002), 10 keys to healthy aging (i.e., use of preventive services [10 Keys™]; Center for Aging and Population Health, 2012), satisfaction and quality of life (e.g., Geriatric Quality of Life Questionnaire [GQLQ]; Guyatt et al., 1993). The complete questionnaire is available from the authors. Interviews with 10 elderly high-rise residents were used to further refine the questionnaire. This testing (cognitive interviewing) is used to help determine whether potential respondents consider a question to be unclear, so that wording of items can be refined (Levine, Fowler, & Brown, 2005). Minor wording changes were made as a result of this cognitive interviewing process.
Data Collection The questionnaires were administered in person. A gift card was used as an incentive to complete the questionnaire (US$10) for both SAH program participants and control group participants. This process was conducted every 6 months over the course of 3 years. Residents were encouraged to participate by building managers, building care coordinators, and the outreach nurse. Each month the data were collected from building managers at the participating high rises on the number of move-ins, move-outs, deaths, and nursing home transfers. The building sites were in very close proximity to a single large integrated health care provider network. Health care utilization data were available for residents (including ER visits, admissions, and outpatient hospital visits) from the provider. Informed consent was given by most residents (i.e., 96%) to view the health care utilization records.
Statistical Approach Identical questionnaires were used at sites receiving enhanced services and those not receiving enhanced services. Chi-square tests were used to determine differences between the groups. Findings are presented comparing prewith post-information in the enhanced group and the control group using the resident data collected. The resident information was collected over six consecutive periods and participation varied in each period. For the enhanced group, participation increased over time from 78 residents to 148 residents. This increase in participation probably reflected greater acceptance of the SAH program. Thus, for both groups some different residents were included in each time period, and different residents had varying degrees of participation in the program. In the analyses presented, the resident responses from December 2008 to June 2009 are combined. These residents had the most exposure to the SAH program. The
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mean scores of these residents from December 2008 to June 2009 are compared with those of the same residents in June 2011. Thus, scores from 104 residents in the enhanced group are compared with 72 in the control group. One limitation of this analytic approach is right censoring (e.g., residents dropping out due to illness or death). Very few residents were subject to this censoring (
