Determinants of Long-Term Care Use

In my work for Dr. Aparna Soni, we are interested in estimating the effect of expanded access to prescription drugs on long-term care (LTC) utilization. Below I sketch out determinants of LTC utilization.

LTC use reflects need for personal assistance, which is caused by some decline in function (disability) and mediated by access to care.

LTC need is determined partially by

  • Disability
    • Social determinants
      • Social isolation
      • Home and neighborhood environment
      • Nutrition
      • Income, wealth, and health care access history
      • Employment and employment type
      • History of stressors including discrimination 
    • Medical determinants
      • Chronic illness
        • onset
        • management
        • exacerbation
      • Progressive illness, esp. dementia
        • onset
        • progression
      • Behavioral health
        • substance use disorder
        • mental illnesses
      • Pain, its management
      • Vision
      • Accidents
        • Home hazards
        • Polypharmacy
        • Vision
        • Nutrition
      • Medical care history
      • History of fitness, nutrition, stressors
  • Use of supportive services that substitute for LTC to allow  aging in place with disability
    • Social services
    • Zoning/Housing walkability
    • Accessibility of housing stock
    • Transitional care management and other medical-provider programs to reduce the burden of complex care needs

LTC access involves

  • affordability
    • financial resources
    • insurance status
      • private LTC insurance (rare – 5% of older adults have plans)
      • Medicare for home health
      • Medicare/Medicaid for the PACE program
      • Medicaid for home, community-based, and facility LTC
  • availability of LTC options
    • nearby formal providers: facilities, including LTACs and IRFs, home care agencies
      • market structure especially Medicaid program design
      • rurality
    • informal help: friend or family member helps
      • objective social isolation/connectedness
      • persons for whom the economic tradeoff of help is worthwhile
        • informal pay
        • opportunity costs
        • intensity of help required

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