LTC Insurance OT Study

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LTC Insurance OT Study

  1. 1. Evaluation in the Long Term Care Insurance Industry An Occupational Therapy Model Cathy Peirce, Ph.D., OTR/L Assistant Professor Nova Southeastern University [email_address]
  2. 2. Acronyms <ul><li>ADL = activities of daily living (all self care tasks (continence; mobility) </li></ul><ul><li>IADL = instrumental activities of daily living (telephone, shopping, food prep, housekeeping, laundry, transportation, medicine & finance management </li></ul><ul><li>LTC = long term care </li></ul><ul><li>KTA = Kitchen Task Assessment </li></ul><ul><li>CPT = Cognitive Performance Test </li></ul><ul><li>AD = Alzheimer’s Disease </li></ul>
  3. 3. Purpose <ul><li>Immediate goal – to compare the outcomes of two different evaluations of older adults upon initiation of a LTC insurance claim </li></ul><ul><ul><li>Older adults living in their homes </li></ul></ul><ul><ul><li>Traditional nursing evaluation </li></ul></ul><ul><ul><li>Occupational therapist evaluation </li></ul></ul>
  4. 4. Potential Benefits <ul><li>Increased likelihood of remaining in their homes as they age as a result of improved capacity to care for self </li></ul><ul><ul><li>Compare change in ADL/IADL performance 3 and 6 months post evaluation </li></ul></ul><ul><li>Maintenance of personal financial resources </li></ul><ul><ul><li>Compare costs generated by those receiving the OT evaluation and those who do not </li></ul></ul>
  5. 5. Significance <ul><li>Need for effective and efficient LTC solutions is growing </li></ul><ul><li>LTC places a financial burden on society and the individual </li></ul><ul><li>Aging in one’s home is preferred </li></ul><ul><li>Caregivers bear much of the burden </li></ul><ul><li>Purchasers of LTC insurance believe the insurance will help them maintain independence </li></ul>
  6. 6. Project Background <ul><li>LTC insurance companies provide services based on assessment of a licensed nurse </li></ul><ul><li>While other services are sometimes recommended, formal caregiving by aides is primary ($18/hour approximate) </li></ul><ul><li>Direct assistance has been shown to have a negative effect on performance </li></ul><ul><li>Decreased levels of activity shown to be modifiable by changes in the person’s environment </li></ul>
  7. 7. Project Background <ul><li>Occupational therapy FOCUS </li></ul><ul><ul><li>Identify the match between the demands of an activity and the capacity of the person to complete a task successfully and safely </li></ul></ul><ul><li>Occupational therapy APPROACH </li></ul><ul><ul><li>Collaborate with the client during an initial interview </li></ul></ul><ul><ul><li>Observe the client perform daily tasks </li></ul></ul>
  8. 8. Project Background <ul><li>Occupational therapy common recommendations </li></ul><ul><ul><li>Adaptations to way of doing things </li></ul></ul><ul><ul><li>Adaptive equipment </li></ul></ul><ul><ul><li>Modifications to the physical environment </li></ul></ul><ul><ul><li>Therapeutic services </li></ul></ul><ul><ul><li>Support services </li></ul></ul><ul><ul><li>*have been shown to increase function/safety in the home </li></ul></ul>
  9. 9. Methods and Procedures <ul><li>Participants </li></ul><ul><ul><li>Older adults “coming on claim” who volunteer to a second initial evaluation </li></ul></ul><ul><li>Location </li></ul><ul><ul><li>Broward County, Fl (Ft. Lauderdale and surrounding communities) </li></ul></ul><ul><li>Dates </li></ul><ul><ul><li>Initiated spring 2007; 3 month pilot planned </li></ul></ul>
  10. 10. Methods and Procedures <ul><li>Data Collection </li></ul><ul><ul><li>Nurse evaluator completes traditional initial assessment </li></ul></ul><ul><ul><li>Obtains permission for second evaluation </li></ul></ul><ul><ul><li>Care manager (CM) contacts occupational therapist </li></ul></ul><ul><ul><ul><li>sets up appointment with ‘claimant’ </li></ul></ul></ul><ul><ul><ul><li>completes a second evaluation using a number of instruments </li></ul></ul></ul><ul><ul><li>CM consults with both evaluators and develops final plan of care; arranges services </li></ul></ul><ul><ul><li>OT and/or CM makes follow-up calls to client </li></ul></ul><ul><ul><li>Services rendered per recommendations and client’s insurance policy coverage criteria </li></ul></ul>
  11. 11. Methods and Procedures <ul><li>Data entry and analysis </li></ul><ul><ul><li>Microsoft Access database management system </li></ul></ul><ul><ul><li>Enter data into excel spreadsheet </li></ul></ul>
  12. 12. Research questions <ul><li>Differences between the nurse assessor findings and those of the OT? </li></ul><ul><li>Changes in the claimant’s performance of key ADLs – areas targeted in plan of care </li></ul><ul><li>Claimant follow up on the recommendations? If not, why not? </li></ul><ul><li>Were readmission rates at 12 months different between a control group who did not receive the OT evaluation and the group that did? </li></ul><ul><li>Differences between direct/indirect costs? </li></ul>
  13. 13. OT Assessment Instruments <ul><li>Barthel Index </li></ul><ul><li>Timed “Up and Go” Test (TUG) </li></ul><ul><li>Kitchen Task Assessment </li></ul><ul><li>Cognitive Performance Test (CPT) </li></ul><ul><li>Short Blessed </li></ul><ul><li>Home Environmental Assessment Protocol (HEAP) </li></ul><ul><li>Company comprehensive initial visit data gathering tool </li></ul>
  14. 14. Barthel Index <ul><li>Simple index of independence reflective of functional status in ADLs; assess change </li></ul><ul><li>Reliability : IR & TRT (.89); IC (.87-.93) </li></ul><ul><li>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 </li></ul>
  15. 15. Barthel Index with help vs independent <ul><li>Feeding 5:10 </li></ul><ul><li>Moving w/chair to bed/return/sit 5-10:15 </li></ul><ul><li>Personal toilet (wash face, comb hair, shave, clean teeth) 0:5 </li></ul><ul><li>Getting on and off toilet 5:10 </li></ul><ul><li>Bathing self 0:5 </li></ul>
  16. 16. Barthel Index with help: independent <ul><li>Walking on level surface10:15 </li></ul><ul><li>*Propel wheelchair 0:5 </li></ul><ul><li>Ascend and descend stairs 5:10 </li></ul><ul><li>Dressing 5:10 </li></ul><ul><li>Controlling bowels 5:10 </li></ul><ul><li>Controlling bladder 5:10 </li></ul>
  17. 17. Kitchen Task Assessment <ul><li>15 minutes: Practical, objective measure: organizational, planning, judgment skills while performing a common task; adults SDAT </li></ul><ul><li>Provides level of assist; measures change </li></ul><ul><li>Mix box of pudding using stove and pour into dishes </li></ul><ul><ul><li>Supplies/equipment available; milk refrigerator </li></ul></ul><ul><ul><li>Instructions written large letters </li></ul></ul>
  18. 18. Kitchen Task Assessment <ul><li>6 categories </li></ul><ul><ul><li>Initiation </li></ul></ul><ul><ul><li>Organization </li></ul></ul><ul><ul><li>Performing all steps </li></ul></ul><ul><ul><li>Proper sequence </li></ul></ul><ul><ul><li>Judgment & safety </li></ul></ul><ul><ul><li>Completion </li></ul></ul><ul><li>0=Indep; 1=verbal; 2=physical; 3=UA </li></ul>
  19. 19. Kitchen Task Assessment <ul><li>Reliability: IRR (.83 for total score); high relationships among variables; high correlation coefficients (.72-.74) suggest domains contribute to cognitive dimension </li></ul><ul><li>Validity: KTA discriminates among different stages of disease (ANOVA); constructs correlated with other neuropsychological/functional tests </li></ul>
  20. 20. CPT: standardized, ordinal scale <ul><li>Developers: Burns, T, Mortimer, J.A., Merchak, P. (1984) </li></ul><ul><li>Purpose: assess functional capacity in people with AD by varying information-processing requirements (cues become more abstract at higher levels) </li></ul><ul><li>Content is 6 ADLs: dress, shop, toast, telephone,wash, travel </li></ul>
  21. 21. CPT <ul><li>Directions: Shop example: “choose a belt that fits you & that you can pay for with the $ in this wallet; pay me the exact amount for..” </li></ul><ul><li>Scoring: </li></ul><ul><li>6= checks wallet , checks price, selects one that fits and pays correct $ </li></ul><ul><li>5 = doesn’t check wallet first etc </li></ul><ul><li>4 = doesn’t recognize errors; verbal assist </li></ul><ul><li>3 = takes a belt, might try on, doesn’t check wallet </li></ul><ul><li>2 = takes belt when handed, does not try on </li></ul><ul><li>1= does not take belt when handed </li></ul>
  22. 22. CPT <ul><li>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 </li></ul>
  23. 23. Timed “Up and Go” Test <ul><li>Short test of basic mobility skills </li></ul><ul><li>Measures, in seconds, time to stand up & walk from standard chair 3 meters, turn, walk back to chair & sit down </li></ul><ul><li>Reliability: Inter RR & Intrarater (ICC 0.99) </li></ul><ul><li>Validity: correlated with Berg balance (r=..81), gait speed (.61) & Barthel (.78) </li></ul>
  24. 24. Timed “Up and Go” Test <ul><li>< 10 freely mobile </li></ul><ul><li>< 20 mostly independent </li></ul><ul><li>20-29 variable mobility </li></ul><ul><li>> 30 impaired mobility </li></ul><ul><li>> 14.5 predictive of fall risk </li></ul><ul><li>< 14.0 no fall risk </li></ul><ul><li>* cognitive task at same time can also be done </li></ul>
  25. 26. Short Blessed Test (SBT) Blessed Orientation-Memory-Concentration test (BOMC) <ul><li>Easily administered; discriminates among mild, moderate, severe cognitive deficits </li></ul><ul><li>Validity: correlation between the MMSE and BOMC was -0.83 (36 persons with AD) </li></ul><ul><li>Reliability: SBT 6 items explained 92.6% variance in total Blessed score </li></ul><ul><li>Predictive of SNF placement (2 years) </li></ul>
  26. 28. HEAP <ul><li>Grouped items (indices) representing number of hazards, adaptations, level of clutter, comfort in 8 areas of the home </li></ul><ul><li>Examples : condition of floor, electrical, door modifications, special equipment/seating, visual cues, objects available for comfort – touch etc </li></ul><ul><li>Reliability (IRR) ranged from slight to perfect </li></ul><ul><li>Validity: preliminary (low MM & more dependent: fewer hazards, more adaptations, less clutter) </li></ul>
  27. 29. Results - Anecdotal <ul><ul><li>3 completed </li></ul></ul><ul><ul><li>Recommendations </li></ul></ul><ul><ul><ul><li>Eliminate or reduce aide </li></ul></ul></ul><ul><ul><ul><li>Shower grab bars </li></ul></ul></ul><ul><ul><ul><li>Shower stool </li></ul></ul></ul><ul><ul><ul><li>Resume clubhouse activities </li></ul></ul></ul><ul><ul><ul><li>Driving risk discussed </li></ul></ul></ul><ul><ul><ul><li>OT for hand arthritis </li></ul></ul></ul><ul><ul><ul><li>Rehab evaluations </li></ul></ul></ul><ul><ul><ul><li>‘ Carry-all’ </li></ul></ul></ul><ul><ul><ul><li>Re-assessment of meds </li></ul></ul></ul><ul><ul><ul><li>Follow-up with physician </li></ul></ul></ul>
  28. 30. References <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Cohen, M.A. (2003) Private long-term care insurance: A look ahead. Journal of Aging and Health , 15, 74-98. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  29. 31. References <ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Life Insurance Marketing and research Association, Long-term care insurance: Trends and outlook. Windsor, CT, 2001. </li></ul><ul><li>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. </li></ul>
  30. 32. References <ul><li>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. </li></ul><ul><li>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, </li></ul><ul><li>Wade, D. T., and Collin, C. (1988). The Barthel ADL Index: A standard measure of physical disability? International Disability Studies, 10, 64-67. </li></ul><ul><li>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. </li></ul>
  31. 33. Thank you – Questions? Cathy Peirce [email_address] 954.262.1223

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