The Pennsylvania domiciliary care experiment: I. Impact on quality of life. Effects of Cash and Counseling on personal care and well-being. Geriatric patient outcomes and costs in three settings: nursing home, foster family, and own home. Medicaid-funded home care for the frail elderly and disabled: evaluating the cost savings and outcomes of a service delivery reform.
This paper reports findings concerning the impact on quality of life of a case management focused program of small board and care facilities serving aging, mental health, and mental retardation adult target populations--the Pennsylvania Domiciliary Care Program. Program participants from the counties in which the Domiciliary Care Program was initiated were matched with persons residing in similar counties without the program who were comparable on a large array of characteristics prior to program initiation. Conducted separately by target group, 10-month follow-up assessments provided the basis for determining impact. In general, the effects were positive, particularly with respect to meeting program quality of life goals (providing needed services, improving living conditions, increasing community integration, and reducing institutional days); the effects were more positive for the aging and mental health than for the mentally retarded target populations. To examine how a new model of consumer-directed care changes the way that consumers with disabilities meet their personal care needs and, in turn, affects their well-being.
                Eligible Medicaid beneficiaries in Arkansas, Florida, and New Jersey volunteered to participate in the demonstration and were randomly assigned to receive an allowance and direct their own Medicaid supportive services as Cash and Counseling consumers (the treatment group) or to rely on Medicaid services as usual (the control group). The demonstration included elderly and non-elderly adults in all three states and children in Florida.
                Telephone interviews administered 9 months after random assignment.
                Outcomes for the treatment and control group were compared, using regression analysis to control for consumers' baseline characteristics.
                Treatment group members were more likely to receive paid care, had greater satisfaction with their care, and had fewer unmet needs than control group members in nearly every state and age group. However, among the elderly in Florida, Cash and Counseling had little effect on these outcomes because so few treatment group members actually received the allowance. Within each state and age group, consumers were not more susceptible to adverse health outcomes or injuries under Cash and Counseling.
                Cash and Counseling substantially improves the lives of Medicaid beneficiaries of all ages if consumers actually receive the allowance that the program offers. Forty-nine matched triads of geriatric patients were compared after three months in their respective placement settings: nursing homes, geriatric foster homes, and own homes with supportive services. Compared to similarly disabled patients in nursing homes, patients in the two community settings made greater improvements in self-care skills and mobility, expressed greater well-being, had similar types and amounts of morbidity, and entailed lower costs. The results support the expansion of home and community-based services as alternatives to institutional care for a substantial number of geriatric patients. In response to rising demand and increased costs for home care services for frail elderly and disabled Medicaid clients, New York City implemented cluster care, a shared-aide model of home care. Our objective: to evaluate the effects of cluster care on home care hours and costs, client functioning, depressive symptoms, and satisfaction.
                Client interviews, conducted prior to implementation and again 16 months later; Medicaid claims records; home attendant payroll files; and vendor agency records.
                The study employed a pretest/posttest design, comparing 229 clients at the first seven demonstration sites to 175 clients at four comparison sites before and after cluster care implementation. Regression methods were used to analyze pre and post-intervention data.
                Cluster care reduced costs by about 10 percent. Most savings occurred among the more vulnerable clients (those with five or more ADL/IADL limitations). Clients at cluster care sites who started out with fewer than five limitations appeared to decline somewhat more slowly than similarly impaired clients at comparison sites, while those with more than five ADL/IADLs tended to decline more rapidly. This difference was small-less than one limitation per year. Cluster care is associated with a significant decline in satisfaction but appears unrelated to depressive symptoms.
                Cluster care appears benign for home care clients with fewer limitations. For the more vulnerable, we recommend experimentation with low-cost interventions that might augment service and improve outcomes without reverting to traditional one-on-one care.
Research in this field is limited. Personal assistance is expensive and difficult to organise, especially in places that do not already have services in place. When implementing new programmes, recipients could be randomly assigned to different forms of assistance. While advocates may support personal assistance for myriad reasons, this review demonstrates that further studies are required to determine which models of personal assistance are most effective and efficient.