ltc insurance ot study
TRANSCRIPT
Evaluation in the Long Term Care Insurance Industry
An Occupational Therapy Model
Cathy Peirce, Ph.D., OTR/LAssistant Professor
Nova Southeastern [email protected]
Acronyms
•ADL = activities of daily living (all self care tasks (continence; mobility)
•IADL = instrumental activities of daily living (telephone, shopping, food prep, housekeeping, laundry, transportation, medicine & finance management
•LTC = long term care
•KTA = Kitchen Task Assessment
•CPT = Cognitive Performance Test
•AD = Alzheimer’s Disease
Purpose
•Immediate goal – to compare the outcomes of two different evaluations of older adults upon initiation of a LTC insurance claim– Older adults living in their homes– Traditional nursing evaluation– Occupational therapist evaluation
Potential Benefits
•Increased likelihood of remaining in their homes as they age as a result of improved capacity to care for self– Compare change in ADL/IADL performance 3
and 6 months post evaluation
•Maintenance of personal financial resources– Compare costs generated by those
receiving the OT evaluation and those who do not
Significance
• Need for effective and efficient LTC solutions is growing
• LTC places a financial burden on society and the individual
• Aging in one’s home is preferred
• Caregivers bear much of the burden
• Purchasers of LTC insurance believe the insurance will help them maintain independence
Project Background
• LTC insurance companies provide services based on assessment of a licensed nurse
• While other services are sometimes recommended, formal caregiving by aides is primary ($18/hour approximate)
• Direct assistance has been shown to have a negative effect on performance
• Decreased levels of activity shown to be modifiable by changes in the person’s environment
Project Background
• Occupational therapy FOCUS– Identify the match between the demands of
an activity and the capacity of the person to complete a task successfully and safely
• Occupational therapy APPROACH– Collaborate with the client during an initial
interview– Observe the client perform daily tasks
Project Background
• Occupational therapy common recommendations– Adaptations to way of doing things– Adaptive equipment– Modifications to the physical environment– Therapeutic services– Support services
*have been shown to increase function/safety in the home
Methods and Procedures
• Participants– Older adults “coming on claim” who
volunteer to a second initial evaluation
• Location– Broward County, Fl (Ft. Lauderdale and
surrounding communities)
• Dates– Initiated spring 2007; 3 month pilot planned
Methods and Procedures
• Data Collection– Nurse evaluator completes traditional initial
assessment– Obtains permission for second evaluation– Care manager (CM) contacts occupational therapist
• sets up appointment with ‘claimant’ • completes a second evaluation using a number of
instruments
– CM consults with both evaluators and develops final plan of care; arranges services
– OT and/or CM makes follow-up calls to client– Services rendered per recommendations and client’s
insurance policy coverage criteria
Methods and Procedures
• Data entry and analysis– Microsoft Access database management
system– Enter data into excel spreadsheet
Research questions
• Differences between the nurse assessor findings and those of the OT?
• Changes in the claimant’s performance of key ADLs – areas targeted in plan of care
• Claimant follow up on the recommendations? If not, why not?
• Were readmission rates at 12 months different between a control group who did not receive the OT evaluation and the group that did?
• Differences between direct/indirect costs?
OT Assessment InstrumentsOT Assessment Instruments
• Barthel Index
•Timed “Up and Go” Test (TUG)
•Kitchen Task Assessment
•Cognitive Performance Test (CPT)
•Short Blessed
•Home Environmental Assessment Protocol (HEAP)
•Company comprehensive initial visit data gathering tool
Barthel Index
• Simple index of independence reflective of functional status in ADLs; assess change
• Reliability: IR & TRT (.89); IC (.87-.93)
• Validity: predicts outcomes of rehab and progress; scores found to agree with other measures of physical disability, compare with other ADL assessment scores, and predict discharge home
Barthel Indexwith help vs independent
•Feeding 5:10
•Moving w/chair to bed/return/sit 5-10:15
•Personal toilet (wash face, comb hair, shave, clean teeth) 0:5
•Getting on and off toilet 5:10
•Bathing self 0:5
Barthel Indexwith help: independent
•Walking on level surface10:15
•*Propel wheelchair 0:5
•Ascend and descend stairs 5:10
•Dressing 5:10
•Controlling bowels 5:10
•Controlling bladder 5:10
Kitchen Task Assessment
•15 minutes: Practical, objective measure: organizational, planning, judgment skills while performing a common task; adults SDAT
•Provides level of assist; measures change
•Mix box of pudding using stove and pour into dishes– Supplies/equipment available; milk
refrigerator– Instructions written large letters
Kitchen Task Assessment
• 6 categories– Initiation– Organization– Performing all steps– Proper sequence– Judgment & safety– Completion
• 0=Indep; 1=verbal; 2=physical; 3=UA
Kitchen Task Assessment
• Reliability: IRR (.83 for total score); high relationships among variables; high correlation coefficients (.72-.74) suggest domains contribute to cognitive dimension
• Validity: KTA discriminates among different stages of disease (ANOVA); constructs correlated with other neuropsychological/functional tests
CPT: standardized, ordinal scale
Developers: Burns, T, Mortimer, J.A., Merchak, P. (1984)
Purpose: assess functional capacity in people with AD by varying information-processing requirements (cues become more abstract at higher levels)
Content is 6 ADLs: dress, shop, toast, telephone,wash, travel
CPTDirections: Shop example: “choose a belt that fits you
& that you can pay for with the $ in this wallet; pay me the exact amount for..”
Scoring: 6= checks wallet , checks price, selects one that fits and pays correct $
5 = doesn’t check wallet first etc4 = doesn’t recognize errors; verbal assist3 = takes a belt, might try on, doesn’t check wallet2 = takes belt when handed, does not try on1= does not take belt when handed
CPT
•Psychometrics: IC .84; IR .91 & TRT.89; MM r=.67; two caregiver scales r=.64; significant decline over time as expected; predictive of institutionalization as well as capacity, needs, safety
Timed “Up and Go” Test
• Short test of basic mobility skills
• Measures, in seconds, time to stand up & walk from standard chair 3 meters, turn, walk back to chair & sit down
• Reliability: Inter RR & Intrarater (ICC 0.99)
• Validity: correlated with Berg balance (r=..81), gait speed (.61) & Barthel (.78)
Timed “Up and Go” Test
•< 10 freely mobile
•< 20 mostly independent
• 20-29 variable mobility
•> 30 impaired mobility
•> 14.5 predictive of fall risk
•< 14.0 no fall risk
* cognitive task at same time can also be done
Short Blessed Test (SBT)Blessed Orientation-Memory-Concentration test (BOMC)
• Easily administered; discriminates among mild, moderate, severe cognitive deficits
• Validity: correlation between the MMSE and BOMC was -0.83 (36 persons with AD)
• Reliability: SBT 6 items explained 92.6% variance in total Blessed score
• Predictive of SNF placement (2 years)
HEAP
• Grouped items (indices) representing number of hazards, adaptations, level of clutter, comfort in 8 areas of the home
• Examples: condition of floor, electrical, door modifications, special equipment/seating, visual cues, objects available for comfort – touch etc
• Reliability (IRR) ranged from slight to perfect
• Validity: preliminary (low MM & more dependent: fewer hazards, more adaptations, less clutter)
Results - Anecdotal
– 3 completed– Recommendations
• Eliminate or reduce aide• Shower grab bars• Shower stool• Resume clubhouse activities• Driving risk discussed• OT for hand arthritis• Rehab evaluations• ‘Carry-all’• Re-assessment of meds• Follow-up with physician
References
• Baum, C. and Edwards, D. F. (1993). Cognitive performance in senile dementia of the Alzheimer’s type: The kitchen task assessment. The American Journal of Occupational Therapy, 47(5), 431-436.
• Burns, T., Mortimer, J. A. and Merchak, P. (1994). Cognitive performance test: A new approach to functional assessment in Alzheimer’s disease. Journal of Geriatric Psychiatry and Neurology, 7, 46-53.
• Cohen, M.A. (2003) Private long-term care insurance: A look ahead. Journal of Aging and Health, 15, 74-98.
• Katzman, R., Brown, T., Fukd, P., Peck, A., Schechter, R. & Shimmel, H. (1983). Validation of a short orientation-memory-concentration test of cognitive impairment. American Journal of Psychiatry, 140(6), 734-739.
• Kristensen, M. T., Foss, N. B., & Kehlet, H. (2007). Timed “Up & Go” test as a predictor of falls within 6 months after hip fracture surgery. Physical Therapy, 87(1), 24-30.
References
• Federal Interagency Forum On Aging Related Statistics, Older Americans 2000: Key indicators of well-being, Retrieved August 2005 from www.aginstats.gov/chartbook2000/Older Amercans2000/pdf
• Gitlin, L.N. (2006). A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults. Journal of the American Geriatrics Society, 54, 809-816.
• Gitlin, L. N., Schinfeld, S., Winter, L., Corcoran, M., Boyce, A. A., & Hauck, W. (2002). Evaluating home environments of persons with dementia: Interrater reliability and validity of the Home Environmental Assessment Protocol (HEAP). Disability and Rehabilitation, 24, 59-71.
• Life Insurance Marketing and research Association, Long-term care insurance: Trends and outlook. Windsor, CT, 2001.
• Mann, W.C., Ottenbacher, K.J., Fraas, L., Tomita, M. & Granger, C.V. , (1999). Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly: A randomized trial, Archives of Family Medicine, 8, 210-217.
References
• Podsiadlo, D. and Richardson, S. (1991). The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39, 142-148.
• Shumway-Cook, A., Brauer S. & Woollacott M. (2000). Predicting the probability for falls in community-dwelling older adults using the Timed Up and Go test, Physical Therapy, 80, 896-903,
• Wade, D. T., and Collin, C. (1988). The Barthel ADL Index: A standard measure of physical disability? International Disability Studies, 10, 64-67.
• Wright, A.P. (1997). Ensuring a responsive long-term care system: New challenge for a new century, Perspectives in Health and Aging, 12 (1), 16.
