The purpose of this qualitative case study was to examine the experiences and perceptions of African American women who reside in a nursing home and to understand African American women's decisions for admitting to the facility. Social Learning Theory was applied to answer the question of how African American women's experiences and perceptions toward long-term care influence healthcare decisions and admission to a nursing home. Eleven participants interviewed in the study were at least 60 years old, admitted into the facility within the past two years and who had not previously resided in a nursing home. Yin's five step approach to data analysis, NVivo and Microsoft Office to gather data from African American women who live in a nursing home. Participants in this study described their perceptions of nursing homes as places they never thought they would reside in and expressed that African American families traditionally "took care of their own." As a result, participants stated nursing homes were not an option normally considered within their families. Decisions to admit to a nursing home were based on family work schedules which resulted in lack of supervision at home, increased nursing care, and financial reasons. Cultural competence was an important factor in helping them adjust to a nursing home environment despite cultural norms. This research can contribute to social change by providing awareness and identifying health behaviors and cultural beliefs regarding the use of long-term care facilities by African American women despite cultural norms. The findings of this study can also create positive social change movement in nursing homes to deliver resident-centered care and empowering staff.

The prescription rate of antipsychotics in patients with dementia varies between 20% and 50% for the common and troubling neuropsychiatric symptoms experienced by patients with dementia. The use of these antipsychotic medications has been linked with increased risk of morbidity and mortality due to associated Parkinsonism, over sedation, gait disturbances, cognitive decline, and cardiovascular adverse events. The purpose of this project was to assess whether development of an evidence-based clinical practice guideline (CPG) for a long-term care facility would increase awareness about issues that govern the safe use of antipsychotic medications. The conceptual framework for the project was Watson's model of caring. The Fineout-Overholt tool was used to rank and score information retrieved following an extensive literature review. An expert panel made up of 2 medical doctors and 4 nurse practitioners had 100% agreement that objectives were clear; content was relevant and easy to understand; the CPG was well-organized and easy to follow; and knowledge learned would be used in practice. From 66.6% to 83.3% agreed that the CGP led to an improved understanding of dementia, neuropsychiatric symptoms, medication adverse events, and nonpharmacologic interventions. The expert panel agreed to launch the CPG upon implementation of an educational program for frontline nursing staff and a behavioral log to track occurrence and frequency of behaviors and the use of nonpharmacologic interventions and their effectiveness in managing behaviors. Safe implementation of this CPG might be adapted to other long-term facilities to optimize dementia care, which would bring about a positive social change.

Family and friends provide substantial daily assistance to older adults with disabilities, but little is known about how that caregiving impacts the health of older adults. Using survey data on a nationally-representative sample of older adults and their caregivers, matched with Medicare claims, I explored several aspects of the relationship between caregiving and the health of older adults receiving care. I relied largely on Andersen’s behavioral model, which describes health services use as a product of predisposing, enabling, and need characteristics. I found that 33%-37% of older adults with unmet care needs at one point in time still have them one year later. I also found frequent change in the composition of older adults’ networks of caregivers. Having a formal caregiver was associated with lower odds of unmet care needs for women; conversely, men receiving care from a spouse had three times lower odds of unmet care needs than those receiving care from a non-spousal caregiver. Some caregivers use services such as respite care, training, and support groups, but some caregivers lack access to desired services. I found that caregivers reporting unmet service need were more likely to be Black and Hispanic, while service use was higher among caregivers providing help on a regular schedule. Care-recipient health and function was associated with both service use and unmet service need, but available measures of local caregiver service supply were not. Older adults frequently seek care in emergency departments (EDs), but this care may not always be necessary or desirable. I hypothesized, but did not find, that caregiver service use was associated with care-recipient ED use. Instead, chronic health conditions and other need factors were the strongest predictors of ED use. I found that care-recipients of male caregivers had lower rates of ED utilization for reasons that were urgent and not preventable. I also found that care-recipients of adult children had lower rates of non-urgent ED utilization than care-recipients of more distantly-related or unrelated caregivers. These findings suggest that unmet care needs might be reduced by improving access to formal care for older women with functional limitations and monitoring unmarried older men. In addition, improving service access for Black and Hispanic caregivers, and for caregivers who provide unscheduled care, could reduce caregivers’ unmet service need. Finally, targeting training and support services to male spousal caregivers could improve access both to needed daily care and to emergency care. Future research should focus on replicating these analyses after more data become available and on developing alternate measures of caregiver service supply.

Lokale Politiknetzwerke werden sowohl in der öffentlichen Sozialstaatsdebatte als auch in der sozialwissenschaftlichen Forschung als vielversprechende Instrumente zur Optimierung von Wohlfahrtsmärkten propagiert. So auch in der Diskussion um den deutschen Pflegemarkt und seine Steuerungsdefizite. Im Gegensatz zu den mit dem Steuerungsinstrument Pflegekonferenz verknüpften Erwartungen, sind dessen genaues Steuerungspotential und mögliche Erklärungsfaktoren bisher jedoch nicht systematisch untersucht worden. Den methodologischen Kern dieser Arbeit bilden eine strukturelle Politikfeldanalyse des deutschen Pflegemarktes in Kombination mit einer empirischen Einzelfallstudie zu den Steuerungsleistungen einer Pflegekonferenz. Grundlage ist ein spezifisches Analyseraster auf Basis des akteurzentrierten Institutionalismus, welches die Aufmerksamkeit in der Analyse der Erklärungsfaktoren auf die Kombination der Koordinationsinstrumente Markt und Netzwerk sowie die Ausgestaltung des institutionellen Rahmens durch Gesetzgebung und Selbstverwaltung lenken soll. Im Rahmen der empirischen Erhebung konnten kaum direkte und nur wenige indirekte Steuerungsleistungen nachgewiesen werden. Als Ergebnis der Analyse lässt sich festhalten, dass lokale Politiknetzwerke im Umfeld des deutschen Pflegemarktes grundsätzlich mit erheblichen Herausforderungen hinsichtlich ihrer Steuerungsfunktion zu kämpfen haben. Dies lässt sich zum einen darauf zurückführen, dass ein gemeinsames Steuerungsinteresse der Akteure nur in wenigen Bereichen vorhanden ist, da die Grundbedingung der Interdependenz selten gegeben ist und auch nur sehr eingeschränkt innerhalb von Pflegekonferenzen entwickelt werden kann. Zum anderen sind die steuerungsrelevanten Handlungsressourcen oftmals lokal nicht verfügbar, wodurch erschwerend die Steuerungsmöglichkeiten eingeschränkt werden. Je nach Steuerungsbereich sind diese Faktoren jedoch verschieden ausgeprägt, sodass sich unterschiedliche Steuerungspotentiale ergeben. / In the public and scientific welfare state debate local policy-networks are propagated as suitable means for strengthening the governance of welfare markets. The same applies to the debate on the German long-term care market and its deficiencies. In contrast to its prominence in the discussion, neither the governance-potential of so-called “care conferences” nor its explaining factors have thus far been systematically analyzed. At the heart of this thesis lies a structural policy-analysis in combination with an empirical single-case study, whereby the institutional design of the German long-term care market is used to explain the performance of a best-practice care conference. An analytical framework based on the actor-centered institutionalism serves as a basis for the analysis. Attention is thus focused on the combination of market and network modes of coordination as well as on the design of the institutional framework of the policy field through legislation and self-government. The evaluation of the care conference showed hardly any direct network-governance and only few indirect governance-results. In the course of the analysis this could be explained by a lack of common interest in collective governance, as the precondition of interdependence between the network-actors is often lacking and difficult to develop within the conferences. Furthermore the collective capability to govern local long-term care markets is in many cases limited, as the necessary institutional resources are seldom locally available. Depending on the area of governance, the influence of both factors varies so that care conferences offer differing governance-potentials. In conclusion care conferences struggle with their governance-function, since the institutional framework and the market leave little room for local network-governance.

According to the Canadian Study of Health and Aging most of the 12,630 Canadians living with advanced dementia reside in long-term care facilities. This number is rising due to an aging population. The purpose of this study is to address an identified gap in our knowledge about what creates pleasure in people with advanced dementia, through first understanding family caregivers’ ways of eliciting and interpreting positive emotions in their relatives and then having the personal support worker (PSW) try these same approaches to see if similar responses are achieved. This study used a qualitative multiple case study design. Data collection methods included digitally recorded interviews and video-recorded observations of interactions between residents and caregivers. A case is defined as a resident with moderately to severely advanced dementia. Each case had two informants: a family member and a PSW meeting inclusion criterion. There were seven cases. The resident participants spanned a range from moderately advanced to severely advanced dementia. Data analysis used both inductive and deductive coding with sensitizing concepts of selfhood, personhood, continuity of personality and well-being. The results of this study centred on four main themes related to the research questions about the sources and indicators of pleasure and the potential for PSWs to replicate what family members did with residents. Some sources of pleasure were lost, some were maintained and new ones developed post-illness in all of the residents. Both family members and PSWs were knowledgeable about sources and indicators of pleasure for the people with dementia they were involved with. The analysis demonstrated that for individuals with very advanced dementia, the concept of pleasure or enjoyment is not applicable. The family members of the two residents with very advanced dementia used music, touch and sweets to elicit a pleasurable response but the resident did not display indicators of pleasure in response; instead, the residents responded with grasping or other responses which require further research to understand fully. Future research should build upon these findings in order to further understand the concept of positive affect: pleasure, interest and enjoyment in people with advanced dementia of the Alzheimer type.

Objective: determine whether accreditation through Accreditation Canada is associated with more favorable resident safety in Ontario LTC homes and which facility characteristics are predictive of accreditation. Methods: logistic regression was used to determine predictors of accreditation. To examine the association between accreditation and safety, safety was operationalized as five MDS-RAI quality indicators: prevalence of falls, restraints, catheters, pressure ulcers, and infections. Separate multivariable models were developed for each indicator. Results: the odds of accreditation were approximately six times smaller for municipal (p < 0.001) and non-profit facilities (p < 0.001) relative to for-profits; three times greater for chains relative to non-chains (p < 0.001); and twice as large for urban relative to rural facilities (p = 0.04). Of the five quality indicators examined, only one (falls) was associated with accreditation. After adjusting for confounders, accredited homes were estimated to have 8% lower fall rates than non-accredited homes (p = 0.01).

University of Macau / Faculty of Social Sciences and Humanities / Department of Government and Public Administration

According to the Canadian Study of Health and Aging most of the 12,630 Canadians living with advanced dementia reside in long-term care facilities. This number is rising due to an aging population. The purpose of this study is to address an identified gap in our knowledge about what creates pleasure in people with advanced dementia, through first understanding family caregivers’ ways of eliciting and interpreting positive emotions in their relatives and then having the personal support worker (PSW) try these same approaches to see if similar responses are achieved. This study used a qualitative multiple case study design. Data collection methods included digitally recorded interviews and video-recorded observations of interactions between residents and caregivers. A case is defined as a resident with moderately to severely advanced dementia. Each case had two informants: a family member and a PSW meeting inclusion criterion. There were seven cases. The resident participants spanned a range from moderately advanced to severely advanced dementia. Data analysis used both inductive and deductive coding with sensitizing concepts of selfhood, personhood, continuity of personality and well-being. The results of this study centred on four main themes related to the research questions about the sources and indicators of pleasure and the potential for PSWs to replicate what family members did with residents. Some sources of pleasure were lost, some were maintained and new ones developed post-illness in all of the residents. Both family members and PSWs were knowledgeable about sources and indicators of pleasure for the people with dementia they were involved with. The analysis demonstrated that for individuals with very advanced dementia, the concept of pleasure or enjoyment is not applicable. The family members of the two residents with very advanced dementia used music, touch and sweets to elicit a pleasurable response but the resident did not display indicators of pleasure in response; instead, the residents responded with grasping or other responses which require further research to understand fully. Future research should build upon these findings in order to further understand the concept of positive affect: pleasure, interest and enjoyment in people with advanced dementia of the Alzheimer type.

With the aging of our population and the higher risk of chronic illness and disability with age, more and more family members may be faced with the experience of having a relative transition into a long-term care (LTC) home. This reality necessitates greater understanding of family care partner needs to ensure wellness throughout their caring career. Using participatory action research, notions of wellness were explored for family partners in care with relatives residing in LTC homes. Using two LTC homes from a privately owned company called Specialty Care, ten family members were interviewed, followed by one focus group at each of the two LTC homes. Three major themes were revealed, each with several sub themes: (1) understanding wellness amidst challenges to keep a sense of wellness in life; (2) self-appraisal: becoming aware of personal beliefs and perceptions that influence wellness; and (3) assessing LTC homes and their influence on the experience of wellness. We not only revealed more about wellness and how it is experienced in the caring context, we also discovered leisure’s role in maintaining wellness and how embedded leisure’s influence is on the various aspects of wellness that family partners in care experience. Relationship-centred care is a framework we used to guide this study. It highlights the importance of family member needs, along with the needs of the residents and staff. With our enhanced understanding of family care partner needs, recommendations were made to the Specialty Care communities so they can work together to ensure optimal wellness is maintained for all parties, including family partners in care.

The purpose of this study is to find existing circumstances in our country and a elder long-term care system of preventing transitions. Through the existing social insurance, for example: health insurance, national pension, labor insurance and the elderly welfare legal in our country, to compare with the other social countries, I hope to use the research analysis to find the problems of policies or legislated process that we need to prevent before the elder long-term care insurance started. Through the generalize analysis and history development of elder long-term care in many countries, use the Constitution and the Administrative Law to examine what Council of Grand Justices about Social Insurance interpretation and compare with the official policy offered by our government. I expect to avoid making mistakes and dispute like before and establishing the elder long-term care system which relieving burdens. After the analysis, I found that all of the advanced countries are almost confronting by problems like aging of population and the birthrate has been decreasing, and also confronting lack of care members and long-term care needed huge monetary payment issues. The key core of all the problems is whether it has enough money to the whole social welfare countries to be successful. Social welfare in democratic countries also face election activities carrying on social welfare politics. Ignoring national finance situations and majority political men were merely thinking off-the-shelf votes. It is priority for elder¡¦s policy but ignores the generation justice issues. Let me worry about whether descendant whom need care, not these elders, are there generations conflict being happened? In my opinion, to solve these problems is strengthening family function. If the whole social and nation wants to be stable, it is important to strengthen the family function. Therefore, the elder long-term care should be considered main family basis, in addition to ought to maintain the elder long-term care system and dualism and co-operate with National Health Insurance to work in coordination. The other elder social insurances have to adjust to unity, includes all kinds of old-age pensions similar nouns. Finally, it should be a definite principle and laws, and decrease indefinite concepts of law and reduce administrative discretion rights regarding pay items, thus it will protect people¡¦s rights instead of incurring damage beyond that could bring supervisory mechanism functions into full play after that.