Thesis advisor: Alicia H. Munnell / This dissertation contains three essays. Each considers an economic decision faced by elderly households. The cost of nursing home care represents a substantial financial risk for older households. Yet, only 10 percent purchase long-term care insurance (LTCI), with many relying on Medicaid. The first essay estimates a structural model of the LTCI purchase decision using Health and Retirement Study data. Estimates indicate that this population has a modest preference for higher quality care and thus Medicaid crowds out LTCI. In addition, housing wealth provides self-insurance against the cost of nursing home care, so that individuals who are "house-rich cash-poor" are less likely to purchase LTCI. I also evaluate public policies designed to stimulate the take-up of LTCI and reduce Medicaid spending. I find that a comprehensive 20 percent subsidy would increase take-up by 160 percent, but the resulting Medicaid savings would amount to only 22 percent of the subsidy cost. A targeted subsidy would be more likely to break even, but would have only a small effect on coverage. Full enforcement of Medicaid estate recovery programs would reduce Medicaid expenditure by 31 percent, but would have insignificant effect on LTCI coverage. The second essay investigates the impact of house prices fluctuations on the non-durable goods consumption decision of older households. House prices in the United States fluctuate over time with significant regional variation. Thus, understanding how these price movements affect households' consumption has important policy implications. Existing studies focus mostly on the working population, leaving the effect of older households, who could be either the largest beneficiaries or victims of house price fluctuations, unexamined. Using Health and Retirement Study data, I show that house price fluctuations significantly affect non-durable goods consumption of older households. Estimates indicate that both the wealth effect and a relaxed borrowing constraint increase consumption when house prices appreciate. In addition, I find that only unexpected changes in house prices lead to changes in consumption of non-credit constrained households, which is consistent with economic theory predictions. Finally, I provide evidence that older households usually fund the additional consumption by increasing mortgage debt, rather than by drawing down financial assets. The third essay evaluates the value of the additional longevity insurance acquired by delaying claiming social security benefit. Individuals can claim Social Security at any age from 62 to 70, although most claim at 62 or soon thereafter. Those who delay claiming receive increases that are approximately actuarially fair. I show that expected present value calculations substantially understate both the optimal claim age and the losses resulting from early claiming because they ignore the value of the additional longevity insurance acquired as a result of delay. Using numerical optimization techniques, I illustrate that for plausible preference parameters, the optimal age for non-liquidity constrained single individuals and married men to claim benefit is between 67 and 70. I calculate that Social Security Equivalent Income, the amount by which benefits payable at suboptimal ages must be increased so that a household is indifferent between claiming at those ages and the optimal combination of ages, can be as high as 19 percent. / Thesis (PhD) — Boston College, 2010. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Economics.

Thesis. 1978. M.Arch--Massachusetts Institute of Technology. Dept. of Architecture. / MICROFICHE COPY AVAILABLE IN ARCHIVES AND ROTCH. / Bibliography: leaves 83-84. / by Thomas Joseph Stohlman, Jr. / M.Arch

Doctor of Philosophy / Department of Human Ecology-Personal Financial Planning / Dorothy Durband / D. Elizabeth Kiss / Using constructs derived from expected utility theory and data from the RAND American Life Panel 2012 Well Being 186 and 193 surveys, this study explored the extent to which financial knowledge, financial risk tolerance, and the uncertainty regarding the future need for long-term care were associated with long-term care insurance (LTCI) ownership by baby boomers (N = 1,152). Although extensive studies have been conducted regarding long-term care (LTC) issues facing baby boomers in the United States (U.S.), no studies have been found that investigate whether or not these specific factors were predictive of LTCI ownership by baby boomers. Regression analysis was used to estimate the relationship between the dependent and the independent variables in this study. Consistent with the hypotheses of this study, LTCI knowledge was statistically significantly associated with LTCI ownership by baby boomers. Subjective financial knowledge regarding LTCI had the greatest influence on LTCI ownership. An examination of items used to measure uncertainty regarding the future need of LTC indicated that merely thinking about needing LTC at some point in the future positively influenced LTCI ownership. Baby boomers with higher household income were also more likely to own LTCI. Results of this study may contribute to the existing literature on LTCI ownership among baby boomers. As the need for, and cost of, LTC are expected to increase as the U.S. population ages, study results may also provide information for financial advisors and other stakeholders to better engage baby boomers in ways that promote comprehensive risk management decision making in retirement planning. More specifically, study results may provide stakeholders with information to better understand factors that influence LTCI ownership by baby boomers.

Employee turnover costs long-term care facilities billions of dollars on an annual basis. The purpose of this correlational study was to examine the relationships between employee turnover intention of certified nursing assistants (CNAs) in the long-term care industry and employee compensation, engagement, job satisfaction, motivation, and work environment. The predictor variables were employee compensation, engagement, job satisfaction, motivation, and work environment. The criterion variable was employee turnover intention. The population of interest consisted of CNAs who were residents of Florida, over the age of 18 years, and employed in the long-term care industry. The theoretical framework that grounded this study was the motivational-hygiene theory. For this study, a sample of 157 participants completed an electronic survey. Multiple linear regression analyses predicted the dependent variables, R-² = .34, F(5, 151) = 15.22, p < .0001. The multiple regression model with 4 of the 5 predictors accounted for significantly more variance in turnover intention than would be expected by chance. Correlation tests resulted in statistically significant inverse relationships between employee turnover intention and employee compensation, engagement, job satisfaction, and work environment. The negative correlation observed between motivation and turnover intention was not statistically significant. The findings in this study may contribute to positive social change by reducing turnover intention while improving the quality of care and reducing costs of care that affect the lives of the long-term care residents, concerned family members, and significant others.

Turnover among direct-care workers in long-term care (LTC) facilities is high, and has a significant impact on residents, leaders, and owners of LTC facilities. The overall turnover costs are also substantial and constitute a significant financial burden in LTC facilities. This systematic review of the literature examined, retention strategies for direct-care workers in the LTC workforce. The information may be used to develop and provide practice recommendations that will help improve retention rates among direct-care workers in LTC facilities. The project design involved a systematic examination of English-only studies from 2001-2004, retrieved from 3 major databases: CINAHL with Medline simultaneous, ProQuest, and Ovid resources. The review led to the identification of 858 publications out of which 17 articles met the inclusion criteria. The manifested variables were critically analyzed and grouped into 8 categories: job training, management style, acknowledgement of accomplishments, career advancements, benefits, peer mentoring, competitive wages and work load. The findings from this systematic review of the literature suggest that several factors affect turnover rates in the LTC setting, including job training, management style, acknowledgement of accomplishments, career advancements, benefits, peer mentoring, competitive wages and work load. This project aims to provide insight to project developers, administrators, researchers, and policy makers concerning factors that affect retention. The information can be used as a catalyst for positive social change and reduce the turnover crisis among direct-care workers in the long-term care setting.

Urinary incontinence affects up to 70% of residents living in a long-term care facility and can affect their quality of life. Specifically, urinary incontinence has a direct impact on older adults in regards to self-esteem, pressure ulcer development, falls, urinary tract infections, and psychosocial wellbeing. The goal of this quality improvement pilot project was to determine if an electronic health record (EHR) assessment tool could help older adults remain continent longer and assist in maintaining an independent lifestyle. Orem's self-care deficit theory and social cognitive theory were used to determine how the electronic health record incontinence template could be used to monitor residents for incontinence and affect the incidence of incontinence. Out of 25 residents, 13 met the requirements for inclusion in the pilot study. Quantitative data were collected and documented in the EHR for 4 weeks and compared to the immediate 4 week period post-implementation of the EHR template. Descriptive analyses of pre- and post-implementation EHR assessments showed there were no EHR assessments completed pre-implementation and 2 residents out of 13 had EHR assessments completed post-implementation. The available data suggested that the EHR template, if edited, could be effective for tracking incontinence. The template needed to address bladder incontinence only rather than bowel and bladder. Feedback from nursing staff indicated that a future study should be conducted over a longer period than 4 weeks to see if results would remain consistent. Nurses working in the long term care environment would benefit from reading this project. This study contributes to social change as evidenced by the residents who remained continent longer by having individual toileting plans partially developed by the template; therefore, they remained a viable part of the community.

As there were few studies of older husbands’ experiences associated with providing care at home for spouses with dementia, the researcher designed a two-stage study to examine their experiences, In stage one, a qualitative paradigm guided one-to-one interviews with sixteen care giver husbands to examine their care giving experiences. Analysis of the interview data guided the identification of four models of care giving related to the past, present and future and an overall model over time. In stage two, a comprehensive questionnaire was developed and questionnaire items were identified from multiple sources. In stage two the researcher utilized a quantitative approach to identify to investigate husbands’ experiences. A representative sample of 71 care giver husbands participated by completing the questionnaire and standardized measures of burden and depression along with other measures of husbands’ characteristics and experiences and levels of wives’ illness and associated behaviour. Predictive models of care giver burden were care giving seen as a ‘job’, effects of care giving on the husband-wife relationship, and use of avoidant-evasive coping strategies by husbands. The best predictive models of care giver depression were use of avoidant-evasive coping strategies and changes in husbands’ emotional health status related to care giving. / Doctor Of Philsophy (PhD)

This study explored the influence of motivations on the volunteer experience. The relationship among motivations. volunteer satisfaction, acceptance and support of the organizational goals, and outcomes of success in the volunteer role (pattern of participation and ombudsman effectiveness) were explored using Multiple Linear Regression analyses. Motivational Systems Theory (Ford, 1992) was applied to the investigation of relationships among these variables. It was proposed that alignment between the individual volunteer's motivations and the organization's goals should predict higher levels of satisfaction, organizational commitment, and success. Psychological aspects of the volunteer experience proved valuable to the explanation of certain indicators of success in the Ombudsman role. The rates of case reporting and the time devoted to the Ombudsman role seemed to be influenced by the importance of particular motivations toward volunteerism, the extent to which these motivations are fulfilled by involvement with the Ombudsman program, and the commitment expressed toward the organization. Communal (offering) motivations were rated among the most important for the majority of volunteers. However, satisfaction scores were higher for both agentic and affiliation motivational factors than for the communal motivational factor. Overall, Ombudsmen were least motivated by motivations characterized as agentic or self-oriented. Volunteers with lower importance ratings for agentic motivations had moderately higher reporting rates than did participants attributing less importance to self-oriented motivations. Volunteers expressed high levels of organizational commitment and overall satisfaction in the role. The more committed these participants were to the organization, the more likely they were to experience satisfaction in their roles, and the more likely they were to express high levels of importance for all factors of motivation in this model. A significant effect was found for the influence of organizational commitment on time commitment, case reporting, and the frequency of visits. Motivational Systems Theory was found to be a useful framework for analyzing the effects of personal characteristics and psychological aspects of the volunteer experience on success and satisfaction in the Ombudsman role. / Graduation date: 2000

Thesis (M. Soc. Sc.)--University of Hong Kong, 2006.

Past research advocates the need for long-term care (LTC) facilities to adopt a person-centred model of care to optimize residents quality of life. The construct of quality of life in LTC has been defined by satisfaction with a set of domains identified by Kane and colleagues (2003). One goal of this study was to determine which domain is the most predictive of overall well-being among LTC residents in a rural setting. Based on past research and on Deci and Ryans (1985; 1991) self-determination theory, satisfaction with autonomy was predicted to emerge as most predictive of overall well-being. The present study also examined the relation between resident quality of life and well-being, and the degree of routinization (i.e., adherence to a rigid, inflexible daily schedule) within the LTC environment. Routinization is conceptually at odds with a person-centred model of care, yet its relation to the well-being of care recipients had not been examined prior. One hundred and ninety-eight residents from 15 LTC facilities in rural Saskatchewan participated in individual interviews to measure their satisfaction with 11 quality of life domains (Kane et al., 2003), and their overall well-being (using the Memorial University of Newfoundland Scale of Happiness; MUNSH; Kozma & Stones, 1980). One hundred and thirty-one staff from the 15 facilities completed a questionnaire designed to assess routinization within the LTC environment. Contrary to predictions, autonomy failed to emerge as a significant predictor of overall well-being among sample residents. The domain of meaningful activity received residents lowest satisfaction rating of the 11 domains, and also accounted for the most unique variance in overall well-being. Routinization was negatively related to resident quality of life, with staff rating routinization higher in facilities which residents reported lower satisfaction with quality of life. Results provide focus for improving the quality of life of LTC residents, and point to areas for further study.