"In the driver's seat": Parent perceptions of choice in a participant-directed medicaid waiver program for young children with autism.

This study investigated families' experience of choice within a participant-directed Medicaid waiver program for young children with autism. Fourteen parents or grandparents participated in in-depth interviews about their experience of choosing personnel, directing in-home services, and managing the $25,000 annual allocation. Key findings included families' preference to hire providers with whom they have a prior relationship, parent empowerment and differences of opinion about parents as teachers.

Role for a labor-management partnership in nursing home person-centered care.

Purpose: To investigate how a partnership between labor and management works to change the organization and focus of nursing home frontline work, supporting a transition toward person-centered care (PCC) in participating nursing homes.

Design And Methods: Using a participatory research approach, we conducted case studies of 2 nursing homes participating in a partnership between a labor union and a provider coalition. The study was designed to reveal whether and how the labor-management partnership supported PCC and to identify challenges to overcome in the future.

Nursing assistants' job commitment: effect of nursing home organizational factors and impact on resident well-being.

Purpose: The purpose of this study was to investigate (a) whether certified nursing assistants (CNAs) are more committed to nursing home jobs when they perceive their jobs as enhanced (greater autonomy, use of knowledge, teamwork), and (b) whether CNA job commitment affects resident satisfaction.

Design And Methods: A qualitative exploration of management philosophy and practice and of CNAs' views of their jobs in 18 Massachusetts nursing homes formed the basis for a survey administered to 255 CNAs in 15 homes. A quality-of-life questionnaire was administered to 105 residents.

Kaiser Permanente's manifesto 2005 demonstration: the promises and limits of devolution.

In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home-and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on "unprofitable" populations, for example, those who are chronically ill, poor, and/or disabled.

Selection bias between 2 Medicare capitated benefit programs.

Objectives: To assess enrollment selection bias between a standard Medicare health maintenance organization (HMO) and a higher-priced social health maintenance organization (SHMO) offering full prescription drug and unique home-based and community-based benefits and to assess how adverse selection was handled through SHMO finances.

Study Design: Kaiser Permanente Northwest offered the dual-choice option in the greater Portland region from 1985 to 2002. Analysis focused on 3 "choice points" when options were clear and highlighted for beneficiaries.

Met needs and unmet needs, and satisfaction among Social HMO members.

This article reports on a survey of 800 members of four Social HMO demonstration sites, who were receiving home-based, community-based, and short-term institutional services under the demonstration's expanded community care benefits. The survey asked whether members needed help in 11 areas, whether they received help in each area from an informal caregiver, whether they wanted more help from the Social HMO, and whether help provided by both was adequate. Satisfaction with the program and with service coordination was also assessed.

Utilization and costs of home-based and community-based care within a social HMO: trends over an 18-year period.

Purpose: Our objective was to describe the utilization and costs of services from 1985 to 2002 of a Social Health Maintenance Organization (SHMO) demonstration project providing a benefit for home-based and community-based as well as short-term institutional (HCB) care at Kaiser Permanente Northwest (KPNW), serving the Portland, Oregon area. The HCB care benefit was offered by KPNW as a supplement to Medicare's acute care medical benefits, which KPNW provides in an HMO model. KPNW receives a monthly per capita payment from Medicare to provide medical benefits, and Medicare beneficiaries who choose to join pay a supplemental premium that covers prescription drugs, HCB care benefits, and other services.

Medicare managed care and frail elders: lessons from social HMOs.

After 20 years of operations, the Social HMO demonstration of integrated acute and long-term care is scheduled to end on December 31, 2004. While a new disability adjustment to the Medicare payment system promises to provide the financial underpinning for continuing to serve the 113,000 beneficiaries now enrolled at four sites, a broader regulatory structure as an alternative to current waivers is also needed. The regulations could also accommodate other frail elderly programs, which serve nursing home residents and beneficiaries of both Medicare and Medicaid.

Community-based care and risk of nursing home placement.

Objective: To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly.

Research Design: The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a "natural experiment." Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999.

Caregiver education and support: results of a multi-site pilot in an HMO.

Caregiver workshops were offered to members by a group practice HMO as part of a larger demonstration of adding community care to HMO services. Of 1,200 members indicating interest at four sites, 532 participated in workshops and 320 completed pre- and post-questionnaires on effectiveness. Analyses showed improvements in caregiving preparedness and reductions in sadness and depression.

The informal community caregiver: a link between the health care system and local residents.

A group of "informal" caregivers, local people to whom residents turn for information and advice, was identified in the east Harlem community and enlisted in a two-month study. Results suggest that formal human services agencies and their intended clientele would benefit by increased efforts on the part of these institutions to locate and work with community caregivers.