U.S. Department of Health and Human Services

Following an Admissions Cohort: Care Management, Claim Experience and Transitions among an Admissions Cohort of Privately Insured Disabled Elders over a 16 Month Period

Executive Summary

Marc A. Cohen, Ph.D., Jessica S. Miller, M.S., and Xiaomei Shi, M.A.

LifePlans, Inc.

May 2007

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This report was prepared under contract #HHS-100-02-0014 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and LifePlans, Inc. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officers, Pamela Doty and Hunter McKay, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Their e-mail addresses are: Pamela.Doty@hhs.gov and Hunter.McKay@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

This is the second in a series of reports based on longitudinal information collected from a sample of 1,400 individuals with long-term care (LTC) insurance, who notified their insurance company that they are receiving or intend to receive paid services for which they will file or have filed a claim under their LTC policy. These individuals comprise “an admissions cohort” of new LTC service users. This admissions cohort has been tracked over a period of 16 months. The purpose of this report is to present selected findings of data collected from the first four follow-up telephone interviews completed after the initial in-person baseline assessment. These interviews were conducted at four-month intervals and examine key issues related to changes in disability status, the use of care management services, individuals’ experience with the claims filing process, and transitions through the continuum of care. We also report on individuals’ satisfaction with providers and their experiences with their LTC insurance. For a more detailed explanation of the larger study, as well as a discussion of findings from the baseline interviews, please see the report entitled “Service Use and Transitions: Decisions, Choices and Care Management Among an Admissions Cohort of Privately Insured Disabled Elders” located at: http://aspe.hhs.gov/daltcp/reports/2006/admcohort.htm. Key findings from the first four follow-up interviews are presented below.

Sample Distribution

• Most of those using paid care throughout the 16 months were residing at home or in assisted living facilities (ALFs).
• The proportion of sample receiving care in any of the service settings does fluctuate over the 16-month period suggesting that there are transitions over the period, although not of a very large magnitude.
• The mortality rate at the first Wave of telephone interviews, four months after baseline is high (11%), which suggests that at least one in ten “new admissions” to the LTC system is very sick, and not likely to be long users of care.

Socio-Demographic Characteristics

• As expected, the age and gender profile of paid care recipients during the follow-up period mirrors that at baseline.
• Those in ALFs remain the oldest and most likely to be widowed, although by Wave 3, there is no significant difference in the age of nursing home (NH) and ALF residents.

Functional Characteristics

• Disability levels remain fairly constant across the Waves and service settings, with those residing in NHs being the most disabled and those in assisted living the least disabled.
• Those who started out at baseline needing help with less than two activities of daily living (ADLs) remain the least disabled over time, increasing to an average of 2.34 ADL limitations by the end of Wave 4.
• For the most part, people are deteriorating over time as is evidenced by the fact that the average number of ADL and instrumental activity of daily living (IADL) limitations increases over time.
• The exception to this general patter is found for those who are most disabled (had between five and six ADL limitations at baseline). While this group remains the most disabled, the average number of ADL limitations drops slightly by Wave 4, which is most likely due to the fact that the sickest or most disabled in this group are dying and the healthiest (in a relative sense) of this group are remaining in the sample.

Satisfaction with Service Providers

• When looking at satisfaction as a dichotomous variable, satisfaction rates in all service settings across all Waves are very high.
• When focusing on those who reported very high satisfaction levels, however, NH residents are least likely to report that they are very satisfied and this group has the largest decline in satisfaction over time.

Use of Care Management

• While the use of care management was low at baseline (19%, 11% and 7% for home care (HC), NH and ALF respectively), there is a significant increase in the use of care management at Wave 1, which is when individuals are putting specific services in place.
• At Wave 1, 35% of HC recipients, 20% of NH residents and 12% of ALF residents reported using a care manager within the last four months.
• Almost all of those who used a care manager found them helpful, responsive to their needs and felt that the care manager spent enough time with them.

Experience with Filing a Claim

• Ninety-six percent of paid care receivers reported filing a claim by the time of the first follow-up interview.
• The majority for whom a decision was rendered was approved -- 95.7% at Wave 1, with 4.3% reporting they were denied benefits.
• At the end of the 16-month period, the adjusted denial rate (total denials over the period) drops to 2.4%.
• Those who were denied state that they were told they were not disabled enough to qualify for benefits yet. In fact, they only have an average of 0.74 limitations in ADLs at baseline and 1.8 at Wave 1.
• Of all those who submitted claims at Wave 1 (both approved and denied), 94% report having no disagreements with their insurance company or that their disagreements were resolved satisfactorily.

The Effect of Having a LTC Insurance

• At Wave 1, roughly three-quarters of claimants agree that having their insurance made it easier to obtain needed services and that number increases to 83% by the fourth follow-up interview.
• The majority of claimants also agreed that having their LTC insurance policy allowed them greater flexibility with the choice of care setting.
• A majority at all Waves stated that they would have to decrease the amount of paid care they receive if they did not have their policies.

Movement and Transitions

• Those who moved to an ALF at baseline were the most likely to remain there over time and also had the lowest cumulative mortality rate.
• Those who began using paid care at home at baseline were the most likely to stop using paid care over time.
• NH residents had the highest overall mortality rate by Wave 4 -- close to one in three were deceased after 16 months, with 21% of these dying four months after entering the NH.
• The highest rate of transitions occurred at Wave 1 with 37% of the sample either changing care settings or going from paid care to no paid care or vice versa.
• For those who were followed for the entire 16-month period, 41% reported no change in care setting or service use, and 46% reported experiencing one transition.
• The average number of transitions for those observed at all points in time was 0.77.
• For those who do transition, they are most likely to be younger, less disabled (both functionally and cognitively) recipients of paid HC and report being less than satisfied with their initial choice of service provider.

The information gleaned from this random sample of an admissions cohort to the LTC system is extremely informative. This is perhaps the first time a random sample of a cohort of new service users in multiple care settings has been interviewed so close to the time of their decision and then followed for a significant length of time (over two years when the study is completed in 2008). Findings presented here underscore the importance of focusing on phenomena over time, rather than at a point-in-time. In this way it is possible to better understand the dynamic nature of the system and those who are accessing it.