September 2008

Grant Results

SUMMARY

Researchers with the Center for Health and Long-Term Care Research, Waltham, Mass., interviewed 1,474 individuals with long-term care insurance policies and followed them for up to two years.

The goal was to examine the factors that influence the kind of long-term services patients choose over time, including:

  • Paid care at home.
  • Assisted-living facilities.
  • Nursing homes.

Key Findings

  • At the time of the initial interviews:
    • 37 percent of respondents were receiving paid care at home.
    • 14 percent of respondents were newly admitted to nursing homes.
    • 23 percent of respondents were newly admitted to assisted-living facilities.
    • 26 percent of respondents expected to begin receiving paid services in the next two months.
  • Respondents in all service settings ranked "having someone available to assist when needed" as the most important consideration in choosing where to receive care. "Feeling safe" was the next most important consideration.
  • Some 93 percent of home-care recipients said that such care was their first choice.
  • Nearly three-quarters (71 percent) of nursing home residents indicated that there were no other options for long-term care in their area.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this research from October 2001 through December 2006 with a $586,352 unsolicited grant.

 See Grant Detail & Contact Information
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THE PROBLEM

In 1900, the senior population (people aged 65 and older) was less than 5 percent of the total U.S. population. By 2001, it was 12.4 percent, and by 2030, it is projected to be 20 percent, according to the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century.

According to the commission, which was established by the U.S. Congress, nearly 20% of seniors today have "significant long-term care needs" and by 2020, the number with disabilities is expected to increase to 7.9 million (from just over 6 million in 2000).

"The need for home- and community-based services will grow substantially owing to the desire for seniors to age in place," the commission concluded.

Such services can cost over $60,000 a year for a semi-private room in a nursing home and $19 per hour for a home health aide, according to the 2005 "MetLife Market Survey of Nursing Home & Home Care Costs."

The challenge ahead for insurance companies and government health care policy-makers will be to predict how and where this growing number of people will actually receive care.

Unfortunately, available data offer only snapshots of an existing senior population at any given time. It does not record the reasons behind the decision to begin using a particular service or move from one service to another.

In an earlier RWJF-funded study, a research team at the Center for Health and Long-Term Care studied how private long-term care insurance affects the level and mix of formal and informal services used. (See Grant Results on ID# 031352.)

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RWJF STRATEGY

For more than 25 years, the Foundation has undertaken efforts to address the health and supportive service needs of older adults and individuals with disabilities of all ages.

Its work has spanned the breadth of long-term care issues, including:

  • Expanding Consumer Choice.
  • Housing and Service Delivery.
  • Caregiving: Direct Care Workforce and Informal Care.
  • Financing.
  • Quality Improvement.
  • Advancing the Long-Term Care Reform Discussion.

As more people live longer with chronic care needs requiring long-term supports and services, it becomes increasingly important to ensure that the nation's long-term care system is appropriately equipped to adapt to this dynamic.

For many of these long-term care programs, RWJF has conducted third-party evaluations. Through data collection and assessment, innovations that appear to have a positive impact can be replicated, and used as the basis for promoting public policies that may one day improve the quality of care and quality of life for individuals with disabilities of all ages. Some examples of RWJF programs that include an evaluation and public policy assessment are:

  • Cash & Counseling.
  • Independent Choices: Enhancing Consumer Direction for People with Disabilities. See Grant Results on the program.
  • The Green House Project. See Grant Results on the Green House Project.
  • Dementia Care and Respite Services Program and its follow-on program, Partners in Caregiving: The Dementia Services Program. See Grant Results on the second program.
  • Medicaid Managed Care.

The Foundation's strategy is fully described online.

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THE PROJECT

Researchers with the Center for Health and Long-Term Care Research, Waltham, Mass., interviewed 1,474 individuals with long-term care policies and followed them for up to two years.

The goal was to examine the factors that influence the kind of long-term services patients choose over time, including:

  • Paid care at home.
  • Assisted-living facilities.
  • Nursing homes.

The study was conducted under the direction of Marc A. Cohen, Ph.D., and Jessica Miller, M.S., of the Center for Health and Long-Term Care Research, a not-for-profit corporation that provides research and analysis in the area of long-term care for both the public and private sectors.

Miller is president of the Center for Health and Long-Term Care Research and Cohen is principal scientist.

Methodology

Study participants were recruited from 10 long-term care insurance companies. (See Appendix 1.) These companies generate in excess of 80 percent of all long-term care claims and are among the major sellers of insurance in the long-term care market.

The investigators conducted a literature review and established a technical advisory group (see Appendix 2) in order to design survey instruments for:

  • An initial in-person interview.
  • Follow-up telephone interviews.

During the in-depth, in-person interview, the investigators collected:

  • Basic demographic information (e.g. age, gender, marital status, education, income level).
  • Information about the nature of the person's disability.
  • The type and duration of long-term care services used.
  • Why a particular service was chosen.

During follow-up telephone interviews the investigators tracked patients':

  • Physical functioning.
  • Experience with the claim process.
  • Use of paid and unpaid care.
  • Reasons for:
    • Changing the kind of care received.
    • Stopping or starting paid care, if they did.

The investigators conducted approximately two years of follow-up, with up to seven additional phone interviews per subject after the baseline interview was completed.

Analysis of the follow-up interviews was completed after the grant closed. (See After the Grant.)

For additional details on recruitment and other methodology, see Appendix 3.

Challenges

  • There was a several-month delay in the start of the project until the investigators received approval of the survey instruments from the federal Office of Management and Budget (OMB), which was required as a condition of funding by the U.S. Department of Health and Human Services (HHS).
  • Obtaining a suitable sample of long-term care users from the participating insurance companies proved to be a much more difficult and lengthy process than was originally envisioned. (See Lessons Learned.)
  • Although response rates for the initial interviews were higher than expected, the sample sizes in subsequent follow-up interviews have been smaller than expected due to the high mortality of study participants over the course of the study.

Funding

RWJF supported this research from October 2001 through December 2006 with a $586,352 unsolicited grant. The investigators also received approximately $600,000 in funding from the Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

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FINDINGS

Research team members reported their findings to RWJF in a "Baseline Interview Report" in December 2006. (Available online.) Findings included:

  • At the time of the initial interviews (conducted between May 2003 and December 2005):
    • 37 percent of respondents were receiving paid care at home.
    • 14 percent of respondents were newly admitted to nursing homes.
    • 23 percent of respondents were newly admitted to assisted-living facilities.
    • 26 percent of respondents expected to begin receiving paid services in the next two months.
  • Since the late 1990s, the proportion of individuals seeking residential care in assisted-living facilities rose, as the proportion choosing nursing homes fell. Specifically:
    • In the late 1990s, 73 percent of residential care claimants were receiving care in nursing homes and 27 percent were enrolled in assisted-living facilities.
    • By 2004, just 38 percent who sought residential care chose nursing homes, while 62 percent began their care in assisted-living facilities.
  • More than one-third of new entrants to assisted-living facilities are over 85 years old and 74 percent are female.
  • Respondents in all service settings ranked "having someone available to assist when needed" as the most important consideration in choosing where to receive care. "Feeling safe" was the next most important consideration.
  • Those who have living children are more likely to enter the service system through the home-care setting.
  • Some 93 percent of home-care recipients said that such care was their first choice.
  • Nearly three-quarters of nursing home residents indicated that there were no other options in their area.

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LESSONS LEARNED

  1. Anticipate difficulty meeting other funders' reporting requirements. The investigators did not anticipate it would take some three months for the federal Office of Management and Budget to approve the survey instruments.
  2. Recognize and account for the differences in the way long-term care insurance policyholders file claims with their carriers. Investigators discovered that the time between the onset of paid care and the filing of a claim varied a great deal, making it more difficult to obtain a reasonable sample of respondents.

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AFTER THE GRANT

The investigators completed an analysis of responses from the first four waves of interviews and, in 2007, published a preliminary report of the findings, available online.

On July 24, 2008, the project director testified before the Subcommittee on Oversight and Investigations of the U.S. House Committee on Energy and Commerce, in a hearing entitled "Long-Term Care Insurance: Are Consumers Protected for the Long Term?" Committee members convened the hearing to address concerns that the needs of individuals with long-term care insurance policies were not being adequately met by providers. The project director joined a panel that included state representatives, a consumer advocate, and a member of the Government Accountability Office, and provided empirical data obtained from the RWJF study on the preferences and received care of insurance policy holders.

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GRANT DETAILS & CONTACT INFORMATION

Project

Decisions, Choices, and Care Management Among an Admissions Cohort of Privately Insured Disabled Elders

Grantee

Center for Health and Long-Term Care Research Inc. (Waltham,  MA)

  • Amount: $ 586,352
    Dates: October 2001 to December 2006
    ID#:  043223

Contact

Marc A. Cohen
(781) 893-7600
MCOHEN@lifeplansinc.com
Jessica Miller
(781) 893-7600
JMILLER@lifeplansinc.com

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APPENDICES


Appendix 1

Insurance Companies

Ten long-term-care insurance companies contributed to this study. They include:


Appendix 2

Technical Advisory Group

Institutional affiliations are those at the time of the group member's service:

Christopher Murtaugh, Ph.D.
Center for Home Care Policy and Research
Visiting Nurse Service of New York
New York, N.Y.

Vicki Freedman, Ph.D.
Polisher Research Institute
North Wales, Pa.

Harriet Komisar, Ph.D.
Health Policy Institute
Georgetown University
Washington, D.C.

Pamela Doty, Ph.D.
Office of Disability, Aging and Long Term Care
Assistant Secretary for Planning and Evaluation
Department of Health and Human Services
Washington, D.C.


Appendix 3

Methodology

The 10 insurance companies sent the research team a total of 2,523 referrals of individuals filing a claim or requesting claims packages in order to file a claim. Of those referrals, 1,823 individuals met the study requirements.

The insured:

  • Had begun using paid services in their current service setting within the last 120 days or anticipated beginning paid service use within 60 days.
  • Had a long-term care (LTC) insurance policy that covered care in all three service modalities: nursing home, home care, and assisted living.
  • Intended to file a claim or had already filed a claim with their LTC insurance company.

Of the 1,823 qualified referrals, 349 refused to participate, giving an 81 percent response rate.

In-Person Assessments
All interviewers were experienced nurses with a minimum of two years of experience in assessing the functional and cognitive status of disabled elders.

The major categories of information collected on the admissions cohort of claimants included:

  • Basic demographic information (e.g., age, gender, marital status, education, income level, presence of children near household).
  • Service use data (e.g. the type, intensity, duration, and start date of formal and family care).
  • Use of care management (e.g. was it offered?).

The interview also focused on the reasons a particular choice was made regarding service use and the extent to which that choice had to do with the availability and/or quality of existing service infrastructure, family support, insurance coverage and care manager recommendation.

Follow-Up Period
After the initial in-person assessment was completed, the research team conducted follow-up telephone interviews to track respondents':

  • Physical functioning.
  • Experience with the claim process.
  • Use of paid and unpaid care.
  • Reasons for:
    • Changing the kind of care received.
    • Stopping or starting paid care, if they did.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Cohen MA, Miller JS and Shi X. Service Use and Transitions: Decisions, Choices and Care Management among an Admissions Cohort of Privately Insured Disabled Elders. December 2006. Washington: Office of Disability, Aging and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services. Available online.

Cohen MA, Miller JS and Shi X. Following an Admissions Cohort: Care Management, Claim Experience and Transitions among an Admissions Cohort of Privately Insured Disabled Elders over a 16 Month Period. May 2007. Washington: Office of Disability, Aging and Long-Term Care Policy, Department of Health and Human Services. Available online.

Survey Instruments

"Initial In-Person Interview Protocol for Admissions Cohort Study," LifePlans, Inc., Waltham, Mass. Fielded May 2003 to January 2005.

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Report prepared by: Peter Meyer
Reviewed by: Richard Camer
Reviewed by: Marian Bass
Program Officer: Nancy Wieler Fishman