Many children are unable to remain in the care of their biological families, and often the only solution is to commit them to long-term foster-care in order to ensure their emotional, physical and social well-being. Children in long-term foster-care in South Africa are subject to impermanence in their living arrangements. Long-term foster-care, in reality, is for an unlimited time-period, during which the biological family can at any time rehabilitate itself and petition the court for the return of the child. This is further exacerbated by childcare legislation which does not provide for legal guardianship in foster-care through termination of parental rights and reconstruction services to natural parents. At present, the move in childcare practice is to institute permanency planning philosophy and tennets for children placed in foster-care in order for them to experience stability and continuity of relationships and family life. The move to implement permanency planning in foster-care is new in South Africa and is not supported through South African research and legislative procedures. There is a definite need for the development of a guideline which will exclude natural parents from resuming the care of their placed child, thereby advocating foster care as the next option of permanency for a child, given the situation where adoption is not a feasible alternative. This guideline can hopefully be utilised to gather data motivating for legal guardianship in foster care, through termination of parental rights, thereby assuring the long-term foster child of permanency in his living arrangements.

The deinstitutionalization movement has challenged administrators and professionals to develop new methods of providing services to handicapped clients who reside in geographically dispersed areas. Geographic dispersion limits the frequency of direct contact with clients and increases dependency on parents or paraprofessionals for program implementation and data collection. A difficulty is that these direct service providers' program implementation or data collection efforts may be reinforced infrequently. This problem may be especially acute when the service recipients are severely or profoundly handicapped. Such individuals have slow rates of learning thus making it difficult for the service providers to discern progress.

Background Population aging has led to an increasing number of older adults living in the community with complex care needs such as functional limitations, cognitive impairment, and multimorbidity. These individuals may need help to remain in their homes, which has created a growing demand for home care. Strategies to manage complex older adults such as home care patients safely in the community typically emphasize robust and integrated primary care. The objective of this thesis is to explore how specific measures of quality in primary care are associated with emergency department use among home care patients in Ontario. Methods I conducted four studies on varying subsets of the same population-based retrospective cohort of long-stay home care patients assessed in Ontario from 2014-2016. The first study was a descriptive examination of the entire cohort that characterized their primary care and other health system use. The second was a case-crossover study among home nursing patients examining whether access to afterhours care modifies the association between home nursing visits and same-day emergency department visits. The third study looked at physician-level provision of primary care home visits and its association with emergency department visits among home care patients with extensive functional impairments. The final study examined and compared associations between continuity of primary and specialty physician care. Results Long-stay home care patients in Ontario are high users of both primary care and the emergency department. Better access to afterhours care reduced the likelihood of an emergency department visit on the same day as a home nursing visit. Patients with extensive functional impairments whose primary care physician who provided higher levels of home visits had lower rates of emergency department use. Finally, better continuity of both primary and specialty physician care were similarly associated with lower emergency department use. Conclusion Better quality primary care integrated with other sectors of the health system is crucial to enabling home care patients to age safety in the community. Access to care is particularly important and can be improved though enhancing the availability of afterhours care and increasing the provision of home visits for those who have difficulty reaching primary care offices. Improving continuity of specialty physician care should be a health system objective alongside improving continuity of primary care. / Thesis / Doctor of Philosophy (PhD) / Older adults receiving home care are a growing population of individuals with complex care needs and high rates of emergency department use. This thesis seeks to characterize the primary care use of home care patients in Ontario and examine to what degree better quality of primary care is associated with less use of the emergency department. My findings indicate that increased access to afterhours primary care, higher levels of primary care home visits, and better continuity of both primary and specialty physician care were associated fewer emergency department visits. In conjunction with other sectors, primary care plays a central role managing older adults with complex care needs in the community. Better quality of primary care, particularly advanced access, can help keep older adults safely at home and out of hospitals as they age.

Home care has been the fastest growing sector in the U.S. healthcare system for over three decades. In 2012, there were over 4.7 million home care patients in the United States. Most of these patients were elders (4 million); and this number is expected to increase as the U.S. population continues to age. One major health concern in this elderly home care population is mental health disorders (MHDs), which have been noted with increasing rates and substantial consequences in local data. However, much of our knowledge on this topic was generated from local studies that had a number of methodological limitations. These include over reliance on local and outdated data, a lack of theoretical foundation, and a lack of statistical justification, which may well account for the high variability across findings. To date, no national investigation has been conducted on this topic, supporting the need for a large-scale study which employs recent data to better understand the prevalence, risk factors and impact of MHDs among home care elders in the U.S. This dissertation study addressed these gaps by using the de-identified national home care dataset, Outcome and Assessment Information Set (OASIS), to: 1) examine the national prevalence of MHDs and MHD-caused medical events in the U.S. elderly home care population, and 2) identify factors associated with MHDs and MHD-caused medical events in this population. The 5% random sample used in this study was consisted of 28,475 elderly home care patients: their average age was 79.41; patients were mostly female, white, Medicare beneficiaries, referred from short-stay acute hospitals, and living with others at home. Approximately 38% of this sample had MHDs, mostly depression (28.0%) and anxiety (18.9%). Compared with other patients, those with MHDs were younger, more likely to be female, smokers, frail, living alone, referred from psychiatric hospitals, cognitively or sensually impaired, in poorer general health, had a recent history of falls or multiple hospitalizations, and evidenced insufficient social support. Among patients identified with MHDs, less than one third (31.8%) received mental health services, including psychiatric nursing services (n=317) and depression interventions (n=4,459). During the 60-day home care episode, 16.95% of the sample had subsequent hospitalizations and 12.72% had subsequent emergent care events; 0.45% of these medical events were directly caused by MHDs. In addition, depression intervention was the strongest risk factor for these subsequent medical events, associated with an approximate two-fold risk for all-cause hospitalizations (HR: 1.943) and emergent care events (HR: 1.974). However, 61.61% (n=2,747) of these high-risk depression intervention recipients did not screen positive for depression at admission. Findings in this dissertation study revealed the high national prevalence of MHDs in the elderly U.S. home care population, and the strong association between these disorders and subsequent all-cause medical events. However, these MHDs were largely under-detected and under-managed in this population, highlighting the need for closer monitoring and targeted intervention through enhanced psychiatric training among front-line home care nurses. Recommendations for further work are made, including the development of an electronic algorithm of identified MHD correlates and risk factors as useful in the development of a nationwide monitoring system for geriatric MHDs in the home care setting.

In the United States, home health care (HHC) is the most frequently used form of post-acute care services. Majority of the HHC patients are elderly and have known activities of daily living (ADL) dependencies. The role of HHC as a post-acute care provider has been emphasized under the Affordable Care Act (ACA) as it is expected that HHC services will help patients stay in the community and reduce acute care hospitalization. Urinary tract infection (UTI) -related hospitalization is an adverse patient outcome that affects elderly patients in the HHC setting. Studies examining the ADLs of HHC patients are limited. Although dependence in ADLs is a known risk factor for hospitalization, no study has assessed the relationship between ADL dependency and UTI-related hospitalization among HHC patients. This dissertation describes the ADLs of elderly patients receiving HHC services, and examines risk of UTI-related hospitalization among this population, specifically the potential risk of ADL dependency. In Chapter One, the problems of UTI-related hospitalization and ADL dependency are introduced and their significance is described. In Chapter Two, an integrative review of the literature describing methods of assessing ADLs in skilled nursing facilities (SNF) and HHC are described. In Chapter Three, a cross-sectional study elucidating the risk factors for severe ADL dependency and predictors of ADL improvement among HHC patients is reported. In Chapter Four, the risk factors for UTI-related hospitalization among HHC patients is reported. In Chapter Five, findings of the three studies are summarized and conclusions are provided including strengths, limitations, and implications for practice and policy. Andersen’s Behavioral Model was the theoretical framework used for this study. The Andersen model posits that health care utilization is a function of patients predisposing (e.g. age, gender, race/ethnicity), enabling (e.g. living alone, insurance status, living condition, primary care giver) and need factors (e.g. ADL dependency level, comorbidity, impaired decision making). This model fits this dissertation because evidence shows that health care utilization (UTI-related hospitalizations) depends on predisposing, enabling and need factors. This was a retrospective cohort research design study based on secondary analysis of the Outcome and Assessment Information Set (OASIS) data set of 154,801 beneficiaries who received home health care services in 2013. Descriptive statistics, bivariate analysis, and multivariable logistic regression analyses were conducted to examine the effect of each individual variable on the outcomes of interest (severe ADL dependency, ADL improvement and UTI-related hospitalizations). The study population was elderly (mean age 77 years), mostly female (65%) and white (79.8%). Key findings indicated that, (a) over 60% of patients had severe ADL dependency, and impaired decision making is a strong predictor of severe ADL dependency, (b) Overall, patients experienced ADL improvement from admission to discharge. However, blacks experienced significantly less ADL improvement compared to Whites. Longer HHC length of stay was also associated with ADL improvement, and (c) For the UTI-related hospitalization outcome model, multivariable analysis showed that Medicaid insurance, severe ADL dependency and impaired decision making was associated with increased risk for UTI-related hospitalization

Thesis (Ph. D.)--Oregon State University, 2007. / Printout. Includes bibliographical references (leaves 98-105). Also available on the World Wide Web.

Thesis (Ph. D.)--University of California, San Diego, 2001. / Vita. Includes bibliographical references (leaves 375-382).

The objective of this research is to reveal the implications of the choice of home- and community-based care as opposed to other policy choices and, using a gendered lens, to find a plausible way of assessing the social and economic effects of this care policy for households, families, and centrally for women. Women’s paid and unpaid work, the continuum of paid and unpaid health/care work, care work, the care economy and community care are reviewed, as well as household structure, unemployment and the provision of health and welfare services in South Africa. The costs of unpaid care provision, methods for and issues to do with measuring time-use, and approaches to valuing unpaid care work are also considered. Time-use and financial cost information obtained as part of the 2004 KwaZulu-Natal Income Dynamics Study qualitative study from 19 family caregivers of 17 terminally ill people in 16 households, is the central source of data. The qualitative study employed a modified extended case study method. The psychological, emotional, social and physical costs of unpaid care work are not counted. Instead, caregivers’ labour time spent in unpaid care work is counted and valued using four methods (average earnings, opportunity cost, generalist, specialist), and financial costs to households of unpaid care provision are also counted. In this way unpaid care work is assigned various costs, a necessary step if this work is to be included in policy making processes. The findings are not representative but make possible some speculation about home-based care in KwaZulu-Natal. Findings on financial costs suggest that the welfare grant to the poorest elderly is subsidising the health services. On average 10 hours are spent by household caregivers in unpaid care work per ill person per day, and women are accounting for the bulk of this time. Moreover, in terms of valuing, most appropriate to the poor in KwaZulu-Natal is the generalist method using the proportionate approach and median earnings rates. If family caregivers were paid for the time spent in unpaid care work and households were reimbursed for their financial costs, for 2004/5 using the low estimate it would cost approximately R585 per month per ill person for unpaid care provision that takes place seven days a week and 10 hours per day (R7,619 per month using the high estimate). When multiplied by the number of AIDS-sick people in KwaZulu-Natal, this spending on costed unpaid care provision exceeds the monthly health and welfare spending on home-based care in KwaZulu-Natal for 2004/5 of approximately R2 million by R104,025,512 million if the low estimate is used. These costs are compared to the costs of a selection of similar public and private interventions in South Africa. Without fail the costs of unpaid care provision do not exceed 26 percent of the costs of alternatives. The findings show that the home- and community-based care guidelines have inequality-creating effects: wealthier families may be able to buy in care if necessary, while poorer families have to provide this care themselves. Moreover, government is saving substantially on the health budget by limiting the provision of public inpatient care. Because of the high costs of operation of both high- and low-cost inpatient centres, as well as home-based care as delivered by NGOs/FBOs/CBOs, the potential for these interventions to deliver to all of those in need of such care, when compared with unpaid care provision, is not great from the perspective of a government seeking to cut costs. The findings show that home-based care is cost-effective for government but not for family caregivers who carry the bulk of care costs. Policy options such as payment for caregiving, the basic income grant and expansion of the expanded public works programme are presented. Since family caregivers are meeting a minimum standard of productive participation, it is argued that a citizen based model of social protection be adopted. Finally, what worked and did not work with regard to the study is used to inform recommendations for improved future research on unpaid care work in South Africa. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2010.

This dissertation, employing an array of theoretical approaches under the rubric of Systems Thinking, explores the reality and experiences of family members that mainly provide care at home for their loved ones who live with or are directly affected by HIV & AIDS. Employing a multidisciplinary approach, the dissertation demonstrates how Systems Thinking, feminist and indigenous knowledge principles can be employed for a better understanding of the contemporary construction of family and experiences of caregivers in an HIV & AIDS context. The discussion of the dissertation is based on data analysed following in-depth interviews with fifteen caregivers of the Bhambayi community. The findings of the study reflect a significant change in the definition and practice of parenting. It was found that HIV & AIDS forces a re-definition of the concept and practice of parenting beyond the traditional boundaries of age, sex and gender. Aligned with this main finding was that parenting practices and coping strategies are largely influenced by a strong commitment to the well-being of the children as well as societal constructs. The thesis of this dissertation is that the HIV & AIDS context and associated gender and cultural stereotypes are principally responsible for a significant shift in the understanding of the concept and practice of parenting within an African context. The study thus submits that a Systems Thinking approach ought to be used by interventionists to better understand and thus contribute towards improving the lives of families or communities in similar circumstance as that of the Bhambayi families. / Thesis (M.Com.)-University of KwaZulu-Natal, Westville, 2009.

The assumption underlying this study is that a spatially well planned and appropriately furnished nursing home facility will help the nurses to perform their work more effectively and accordingly lead to more satisfaction for the residents. Research in the forms of a literature review, a movie analysis, and a field study of nursing homes in Germany and the USA, including plan annotations and observational mapping, trace study analyses and survey techniques, was conducted and revealed an unexpected urgent need for nursing home design improvement, especially in the U.S. The research results led to the development of a catalogue of patterns which are useful in the design and planning of a nursing home to improve nurses’ effectiveness in administering care to fulltime residents of nursing homes. With the help of the developed patterns, suggestions for building renovations of two of the researched nursing homes, one American and one German, were given. / Department of Architecture