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1 ms is to certify that the

dissertation entitled

THE SURVIVAL OF THE CHRONICALLY-ILL
ELDERLY AS A FUNCTION OF HOME

CARE SERV I.CES
presented by

SUSAN CHRIST I NE HEDRICK

has been accepted towards fulfillment
of the requirements for

PH . D . degree in PSYCHOLOGY

/' 1/4 [(7 I

Major professor

Date 7‘29-82

 

MS U is an Affirmative Action/Equal Opportunity Institution 0-12771

 

 

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THE SURVIVAL OF THE CHRONICALLY-ILL
ELDERLY AS A FUNCTION OF HOME
CARE SERVICES

By

Susan Christine Hedrick

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

l982

ABSTRACT

THE SURVIVAL OF THE CHRONICALLY-ILL
ELDERLY AS A FUNCTION OF HOME
CARE SERVICES

33/

Susan Christine Hedrick

Evaluation of the patient outcomes associated with home
health care services is a crucial task in the development of a more
effective long-term health care system. This study was designed to
evaluate the association between one type of home care and the ulti-
mate outcome of patient survival, based on the unexpected finding
that half of the studies reviewed here found a significant associa-
tion between community-based services and that outcome.

The survival data analyzed here were collected in a major
experimental study in which eligible patients in five sites in
Michigan were randomly assigned to receive home care services or to
be in a no-treatment control group (Papsidero et al., 1979). The
multi-stage analysis strategy applied to these data in the present
study included combinations of the following approaches: 1) a com-
parison of survival rates of the total experimental and control
groups as well as those of those experimental group patients who
actually used the services and a group of similar control group
patients formed through the use of discriminant function; 2) the

use of two operationalizations of survival; 3) the inclusion of

Susan Christine Hedrick

13 measures of the patients' intake health status as covariates; and
4) the operationalization of the treatment variable as the number of
home care visits received.

The non-significant results of these analyses provide no
support for any relationship between the type of home care studied
and survival. The results do underline the critical need for further
research to help clarify what types of community-based services have
what effects for what types of elderly patients to help qualify the
oversimplistic statements on the effects of these services appearing

in the policy literature.

 

Papsidero, J.A., Katz, S., Kroger, S.M.H. and Akpom, C.A. Chance for
change: Implications of a chronic disease module study. East
Lansing: Michigan State University Press, 1979.

DEDICATION

To my parents.

ii

ACKNOWLEDGMENTS

First, I would like to gratefully acknowledge the guidance
of my committee, Bill Davidson, Chair; Sidney Katz; Jack Condon;
and Charlie Johnson. Their long-term support and encouragement was
invaluable. The guidance and friendship of former and present
faculty, students, and staff of the Ecological Psychology Interest
Group, especially that of Deb Bybee, and Lou Tornatzky, my former
Chairperson, was a great help through these years.

I also gratefully acknowledge the support and research
opportunities gained over these years at the Department of Community
Health Science, Colleges of Human and Osteopathic Medicine. My
research was supported in part a) by a grant (HS-03760) from the
National Center for Health Services Research, Department of Health
and Human Services, b) by a subcontract from the Urban Institute
under a contract (HHS-lOO-80-Ol58) from the Office of the Assistant
Secretary for Planning and Evaluation, Department of Health and
Human Services, c) by a grant (General Research Support) to the
College of Osteopathic Medicine from the National Institutes of
Health, and d) by a grant (DAR-782-0374) from the National Science
Foundation.

A large debt of gratitude is owed to the staff of the Chronic
Disease Module project, under the guidance of Sidney Katz and Joe

Papsidero, for their impressive dedication and hard work in completing

this research endeavor and to the study participants who are still

contributing to our knowledge of chronic disease and its care years

after the study's completion.

Finally, I would like to acknowledge the professional cleri-

cal work by Gail Gubry and Ruth Berg.

iv

TABLE OF CONTENTS

LIST OF TABLES.

INTRODUCTION .

The Effects of Community- -Based Services on Survival
Study Characteristics . . . . . .
Total Group Comparison Results
Meta-Analysis . . . .

Study Characteristics Review .
Subgroup Analyses. . . .
Age . . . . . .
Sex and Race
Living Arrangement and Diagnosis.
Physical Functioning. .
Nursing Home Placement .
Subgroup Results Summary
Summary and Rationale
Research Questions

METHODS. .
Subjects and Setting.
Design .
Service Delivery Procedures . .
Data Collection Procedures. . . . . .
Measures. . .
Demographic Measures. .
Physical Health Status . .
Psychosocial Health Status.
Study Process . .
Treatment Process.
Outcome . .
Data Reduction.

RESULTS . . . . . . . . . . . . . . . .

1. Experimental Distinction with Survivorship . .

2. Experimental Distinction with Length of Survival .

3. Experimental Distinction with Survivorship with
Covariates. . .

4. Experimental Distinction with Length of Survival
with Covariates . .

5. Quasi-experimental Classification with Survivorship

6.

Quasi-experimental Classification with Length of
Survival . . . . . . . . .

Page

vii

Page

7. Quasi-experimental Classification with Survivorship

with Covariates. . . 77
8. Quasi-experimental Classification with Length of

Survival with Covariates. . . . . . . 77

9. Service Intensity with Survivorship. . 78

10. Service Intensity with Survivorship with Covariates 79

Interactions . . . . . . . . . . . . . . 80

DISCUSSION. . . . . . . . . . . 82

Directions for Future Research. . . . . . . . . 9l
APPENDICES

APPENDIX A - Description of Variables. . . . . . . 94
Appendix B - Data Collection Instruments. . . . . . lOZ

REFERENCES. . . . . . . . . . . . . . . . . 123

vi

TABLE

\IO‘Ln-hw

LIST OF TABLES

Review of Studies Assessing Effect of Community-
Based Services. . . . . . . . . .

Number of Persons in Referral Profess and Referral
Sources . . . . . . . . . . . .

Percent of Home Visit Time in Various Activities
Outcome Data Availability by Study Time Period .
Principal Measures . . . . . . . .

Data Analysis Plan

Summary of Regression Predicting Survivorship

vii

Page

38
47
51
56
7O
73

CHAPTER I
INTRODUCTION

A major problem in public policy today is the provision of
long-term health care to the nation's chronically ill elderly in a
way that most appropriately meets their needs while at the same time
making efficient use of the country's finite resources. Many factors
are converging at present which make increasingly crucial the inves-
tigation of modes of health care that are possible alternatives to
the current system. These factors are increasing the size and com-
plexity of the problem of providing appropriate health care services
to the elderly while simultaneously decreasing the ability of the
current medical care system to deal with those problems. Anne Somers
(l978, 1979), in her valuable diagnosis and prognosis of the problem,
cites a number of factors which will be briefly listed here. She
divides the factors into those on the demand side of the equation,
the health consumer side; and those on the supply side, the health
care provider side.

On the demand side, first, the proportion of elderly in the
population, especially of those over 85, is growing at an ever
increasing rate. Secondly, environmental and behavioral threats to
health care are increasing in prominence. Thirdly, the dominant
pattern of illness in the population had changed from infectious
acute (short-term) illnesses that could be cured with an antibiotic

l

to the degenerative diseases such as heart disease, cancer, or stroke
that are chronic (long-term) disabling conditions that cannot be so
easily eliminated. Fourth, the traditional social supports for the
chronically ill elderly are less available with the decline of the
extended family, the nuclear family, the traditional close-knit
neighborhoods, and the increase in the number of working women. The
increasing disparity in life expectancies between men and women also
is a factor as it results in an increasing number of elderly widows
with drastically reduced social and financial supports.

Fifth, the population has been led to have rising and unreal-
istic expectations of "modern medical miracles," counting on the
system to provide them with "enduring youth, beauty, and emotional
and social well-being" (Somers, l979, p. 108) with no changes in
their habits or lifestyles. A final factor on the demand side is the
uneven removal of financial barriers. Public and private health
insurance have both been skewed toward financing acute care in general
hospitals and care in nursing homes, both institutional settings,
and away from ambulatory and home care. Since the choice of the type
of medical care sought is greatly influenced by whether the insurance
company will pick up the tab, acute general hospitals and nursing
homes are often chosen when other types of care would be much more
appropriate for the patients' needs.

Supply side factors include the "technological imperative,"
found in many other fields as well, where technology becomes an end

in itself. In health care, it results in an ever increasing

"intensity" of care, where more procedures, and increasingly sophis-
ticated procedures, are being performed for each medical condition,
often with no evidence of their effectiveness. This is felt by many
observers to be the biggest single cause of rising health care costs.
A related factor is the continued dominance of the acute care
model of medicine, in spite of the aforementioned modern pattern of
illness where chronic conditions predominate. The acute care medical
model has led to a medical care system that is increasingly failing
to meet the unique needs of long-term care patients (Shanas and
Maddox, l976). These patients have multiple interacting dynamic
medical conditions needing continuing management over time. The
patient and family need education and support in dealing with their
disabling conditions and their changes over time. Patients have
psychosocial needs in relation to the stress of the conditions,
changes in social role and economic status, death of spouses and
friends and resulting social isolation, and geographic relocation.
Patients also have needs for basic living supports including house-
keeping, supervision for personal safety, and often need help with
activities of daily living such as bathing and dressing. At the
same time, it is important not to provide unnecessary services, place
the person in an unnecessarily restrictive environment, cut them off
from their communities, and create unnecessary dependencies. The
current system is not providing the necessary mix of service, begun
and ended, revised and coordinated, over time, in response to changes
in needs and changes in response to the services. Dependence on the

two types of care principally used today: short-term uncoordinated

stays in the acute general hospital, and long-term unmonitored stays
in nursing homes, cannot adequately provide these services.

At the same time as the current system is failing to meet
patient needs, it is consuming such an ever increasing amount of
funds that expenditures to the elderly are the major component of
all social welfare expenditure (McMillan and Bixby, 1980).

Total expenditures on health care rose from $12 billion in
1950 to over $160 billion in 1977, and have doubled as a percent of
the GNP and more than doubled as a percent of personal income during
that time. As the per capita cost of health care for elderly persons
is three times as high as for younger persons, is rising faster than
for younger persons, and is more likely to be paid for through public
funds, expenditures for the elderly inevitably are subject to greater
public scrutiny and demand for cost controls (Somers, 1978, p. 163).
The unexpected and seeming uncontrollable cost experience under Medi-
care and Medicaid are a major factor in the continued postponement
of national health insurance, in the failure to extend benefits to
more adequately cover the long-term care needs of the elderly, and
finally, in the reduction of the value of Medicare benefits them—
selves, with the elderly currently paying even more of their medical
costs out-of—pocket now than they did in 1959 (Somers, 1978).

Home care, the provision of services to people in their
places of residence, has been the subject of greatly increased
interest because of its potential for both better meeting the needs
of many chronically-ill patients ang_reducing the exponentially

increasing the costs of long-term care. There is no shortage of

literature which asserts that home care services can have these bene-
fits (Blum and Minkler, 1980; Brickner, Janeski, Rich, Duque, Starita,
LaRocco, Flannery and Nerlin, 1976; Colt, Anderson, Scott and
Zinmerman, 1977; Comptroller General of the United States, 1977;
Somers and Moore, 1976; VanDyke and Brown, 1972). A recent National
Technical Information Service bibliography (no date) for the years
1964-1980 lists 229 references on home care programs. It must be
noted that many studies that purport to evaluate the effectiveness
of the programs, especially those done in earlier years, were very
unsophisticated methodologically. Some cited isolated case studies
as proof of efficacy, others presented outcome data based on esti-
mates of treatment effects by the personnel delivering the services.
Furthermore, many recent observers have agreed that, as in other
fields, the more rigorously designed program evaluations have demon-
strated few significant effects and have not resulted in any con-
clusive consistent accounting of the outcomes that might be expected
from a home care program (Doherty, Segal, and Hicks, 1978; Dunlop,
1980, Iglehart, 1978; Kane and Kane, 1978, 1980; Urban Institute,
1978). Kane and Kane (1980) conclude that:

It would indeed be ironic if alternative mechanisms for care

of the elderly such as a home care services network were

developed only to prove more expensive than nursing home

care without eliminating fraud and abuse or even improving

the well-being of the elderly.

This study is designed to add to our knowledge of home care

services by investigating the association between a particular type

of home care service and a particular outcome, survival.

The Effects of Community-Based
Services on Survival

Twelve experimental or quasi-experimental studies could be
located that evaluated the outcomes of community-based services and
included data on survival rates. These studies will be reviewed here.

The studies include a diversity of types of service programs
studied; types of patients included; and designs, procedures, and
analysis techniques used, all with obvious influence on the results
and implications. Therefore, a tabular review that could highlight
these differences is found in Table 1. It should be noted that
several of the more recent studies, notably Skellie and Coan (1980),
Hughes, Cordray, and Spiker (1980), and Weiss (1981), are still in
progress and only preliminary results are presented. There are sec-
tions for each study containing the references to the major publica-
tions on the study; the study design; the sample, including the N
in the experimental (E) and control (C) groups and criteria used to
select the sample; and a summary description of the service program
or programs studied. Data are presented for the_§_and g groups as
a whole during the study period, expressed in number or percent,
whichever is given in the original document. Results are presented
for selected subgroups of patients, if such analyses were done. The
probabilities of survival computed in a life table analysis done in
one study, and part of the results of a multiple classification
analysis of factors effecting survivorship done in another are pre-

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19

These results are presented both to indicate the findings in
the literature regarding the effect of community-based services and
to illustrate the varied approaches taken to the analysis of this
type of data. Tests of the significance of the differences in out-
comes between the experimental and control groups were reported in
some studies and are presented in the results column of the Table.

No significance tests were reported for the data in other studies.
The statistical significance of the differences in outcomes in these
studies was computed for this review using the chi-square procedure.
These results were then entered in the Table. The levels for all
tests are given as *59 <.05, **fiE <.0l, and ***fiE’<.OOl.

The information in Table 1 will be discussed in the following
manner. First, the characteristics of the twelve studies will be
summarized. Next, a summary of the published results of the compari-
sons made of the total service and comparison groups will be presented.
A meta-analysis performed to further explore the results of the
studies will then be described. The next section will describe the
examination made of the characteristics of the studies to determine
if the design, or sample size, or follow-up period, etc. seemed to
be related to the results. Finally, the results reported from those
studies that analyzed the results separately for subgroups of subjects

will be presented.

Study7Characteristics
Ten of the twelve studies reviewed in Table l were true

experiments, with subjects randomly assigned to groups. The studies

20

by Bryant, Candland, and Lowenstein (1974) and Hughes, Cordray, and
Spiker (1980) were quasi-experiments, comparing the subjects receiv-
ing the experimental services with matched comparison groups. Sub-
jects in the studies were assessed at prescribed intervals after the
initiation of services with the follow-up periods lasting from nine
months for some studies (Bryant et al., 1974; Hughes et al., 1980;
Nielsen, Blenkner, Bloom, Downs, and Beggs, 1972) to five years for
Blenkner, Bloom, Nielsen, and Weber (1974), with most having a one
or two year follow-up period. The length of the follow-up period
was not reported for two studies (Bakst and Marra, 1955; Applebaum,
Seidl, and Austin, 1980). The number of subjects ranged from 50 for
Bryant et al. (1974) to 417 for Applebaum et a1. (1980). Subjects
were selected from populations of patients discharged from specified
institutional settings in five of the studies (Bakst and Marra, 1955;
Bryant et al., 1974; Katz, Ford, Downs, Adams, and Rusby, 1972;
Nielsen et al., 1974; Posman, Kogan, LeMat, and Dahlin, 1964) and in
the rest of the studies from community residents who were referred to
or referred themselves to the service program studied. Most studies
had criteria for admission to the study sample which included 1)
being at least a certain age, 2) having a need for service defined

in terms of having a chronic condition and/or being unable to perform
daily tasks and/or meeting the Medicare/Medicaid nursing home admis-
sion eligibility requirements, and 3) not having a need for the
intensive skilled nursing services or 24-hour a day supervision not

provided in most community-based service programs.

21

The types of community-based services evaluated in these stud-
ies could be divided into three groups although these groups can serve
only as a very basic scheme for categorizing service programs that
undoubtedly differ on many dimensions. The first type is services
provided in the home by a paraprofessional home health aide or home-
maker. This type of service was studied by Applebaum et al., 1980;
Nielsen et al., 1974; Selmanoff, Mitchell, Nidlak, and Mosshandler,
1979; and in the homemaker study by Neissert, Han, and Livieratos,
1979. (It should be noted here that the Heissert et a1. study actu-
ally consisted of evaluations of three types of service modalities
studied simultaneously at different sites, making the total number
of studies reviewed here 14.)

The second type of services are those provided in the home by
a registered nurse. Bakst and Marra (1955), Bryant et a1. (1974),
Katz et al. (1972), and Posman et a1. (1964) studied this type of
care. The rest of the studies evaluated various other types of com-
munity-based care including intensive social work case management
(Blenkner et al., 1974), services in an adult day care center (the
day care study of Weissert et al., 1979) and a “channeling" type
service where a central staff arranged for and coordinated a wide
variety of community-based services (Hughes et al., 1980; Skellie

and Coan, 1980; Weiss, 1981).

Total Group,Comparison Results
The results of these fourteen studies can now be examined.
The results for the comparisons of mortality rates for the total

experimental and control groups indicates that six studies found

22

that the experimental groups had a significantly lower mortality

rate than the control groups (Bryant et al., Selmonoff et al.,

Skellie et al., and all three studies of Neissert et al.). Skellie
et al. (1980) found a significant difference favoring the experimental
group not only in the number of patients who survived to the follow-
up time but also in the number of days subjects survived from the
beginning of the study. Neissert et al., (1979) performed a multiple
classification analysis and found that the use of day care and the

use of homemaker services were significant factors affecting survivor-
ship.

One study found that the experimental group had a signifi-
cantly higher mortality rate than the control group (Blenkner et al.).
Seven studies found no significant difference between the groups
(Applebaum et al., Bakst and Marra, Hughes et al., Katz et al.,
Nielsen et al., Posman et al., weiss). It would seem that these
results (six positive, one negative, and seven no difference) can be
summarized at this point as indicating that community-based services
do have significant effects on survival in at least some situations.
Further explorations of these results were conducted to help clarify

the findings.

Meta-Analysis

A very basic attempt at meta-analysis (Glass, 1981) was made
by combining the data from all fourteen studies where data were
available into one analysis. The number of subjects in all fourteen

experimental groups who were dead at the end of the study period was

23

summed as was the number of deceased control group subjects, and the
number alive in each group. This resulted in a 2 x 2 table which
yielded a chi-square of 22.36, p_< .0003. This finding could help
support a general conclusion that community-based services do have

a positive effect on survival rates.

Study Characteristics Review

The characteristics of the studies were examined to see if
any pattern could be seen that could indicate in which situations
the significant effects were most likely to be seen. For example,
if most of the studies in which significant differences were found
were those with relatively long follow-up times and most of those
in which significant differences were not found were those with rela-
tively short follow-up times, then this could indicate that the
length of the follow-up time was important and possibly that dif-
ferences would have shown up in more studies if the follow-up times
had been longer. However, clear evidence for this kind of situation
was not found. The studies in which significant differences were
reported had short, medium, and long follow-up times. Some evidence
for a follow-up time effect could be derived from the Blenkner et al.
study, where the differences for the total group were not significant
until the third year of follow-up. Likewise, the design of the study
did not seem to influence the findings as the two quasi-experimental
studies included one with a significant difference and one with a
non-significant difference. The number of subjects involved did not

seem to be related to the findings as some studies with differences

24

used relatively small numbers of subjects and others relatively large
numbers of subjects. The source from which the subjects were sampled
--institutions or the community--did not seem to be associated with
the results.

For an examination of the type of services studied--home
health aide, registered nurse, or other--another basic meta-analysis
was performed. The data were combined for just those studies evalu-
ating the home health aide type of service and the experimental and
control group mortality figures were compared. This process was
repeated for the studies evaluating the other two types of service.
For the home health aide studies, 16% of the patients in the combined
experimental groups were dead compared with 26% in the combined
control groups. In the other service studies, 16% were dead in the
combined experimental groups compared to 23% in the combined control
groups. In the registered nurse studies, 27% were dead in the com-
bined experimental groups and an equal 27% in the combined control
groups. An examination of the differences in mortality rates for
the three types of service indicate that the home health aide service
may most warrant further study.

A more sophisticated meta-analysis of these studies could be
performed with more detail about the designs of the studies, the
samples obtained, and with process data about the characteristics
and intensity of the services actually rendered. Unfortunately,

this information is not often available in the study publications.

25

Subgroup Analyses

As a final approach, the mortality findings for various sub-
groups of subjects within each study can be compared across studies.
This approach could help to indicate the type of person for whom
community-based services could have the greatest potential survival
effects. Separate data analyses for subgroups of subjects were per-
formed in the studies by Katz et al., Nielsen et al., Blenkner et al.,
all three studies of Neissert et al., and Skellie et al. The Katz
et al. study analyzed the results separately for subjects divided
into 71 subgroups or "intake classes" that had been formed based on
subject's scores on various combinations of demographic, physical
health status, and psychosocial health status measures. The result-
ing statistics were not published but it was stated that there were
no significant differences in mortality for patients in any of the
subgroups.

The other studies performed separate comparisons for a smaller
number of subgroups that had been formed based on scores on single
variables. As the same subgrouping variables were used in more than
one of these studies, these results can be compared profitably across
studies. Different combinations of eight different variables were
used to form subgroups in these studies: age, sex, race, living
arrangements (availability of a potential care giver in the home),
diagnosis, functional status in the activities of daily living (ADL)
(level of independence in performing such activities as bathing,
dressing, feeding, and continence), functional status in the instru-

mental activities of daily living (level of independence in

26

performing such activities as laundry, housecleaning, telephoning,
paying bills, taking medication), and placement in nursing home at
any time during the study. The subgroup comparisons using these
eight variables will each be discussed in turn, and then the results

will be summarized.

Agg,--Age was used as a subgroup variable in five of the six
studies and significant differences were found in four. In three of
these studies (Blenkner et al., for the first, second, and third
years of follow-up; and the day care and day care plus homemaker
study of Neissert et al.), younger subjects, those less than 75 years
of age, had different mortality rates in the experimental group while
the Blenkner et al. study found higher rates.

0n the other hand, the Heissert et al. homemaker study and
Blenkner et a1.'s six-year follow-up analyses reported that the sub-~
jects 75 years of age and older, rather than the younger subjects,
were those who had a different mortality rate. As usual, the Weissert
et al. study found lower rates in the experimental group while

Blenkner et al. found that group to have higher rates.

Sex and Race.--Groups were classified by sex in five studies.

 

In no case were there differences between groups for males or females
(Blenkner et al., Nielsen et al., and all three studies reported in
Neissert et al.). The three Neissert et a1. studies used race as a
subgroup variable. The homemaker and homemaker plus day care studies

found that white subjects had significantly lower mortality rates in

27

the experimental condition while non-white subjects showed no such
differences. The day care study found no differences for either

subgroup.

Living Arrangement and Diagnosis.--Five studies used the
subjects' living arrangements as a subgroup variable. In three of
these studies there were differences. In each case, the subjects
who lived with other persons had lower mortality rates in the experi-
mental group than in the control group while no such differences were
found for those who lived alone (Skellie et al., the day care and
homemaker studies in Neissert et al.). Diagnosis was not a useful
subgrouping variable in these studies as none of the four studies

using it found subgroup differences.

Physical Functioning.--Initial level of physical functioning
in the activities of daily living (ADL) interacted with the treatment
condition in two of the five studies using this measure. The Neissert
et a1. day care plus homemaker study found that both those with the
lowest level and those with the highest level of functioning were
likely to have lower mortality rates in the experimental group, while
the homemaker study found that only those in the lowest functioning
group had such a result. Only Skellie et al. used the level of
functioning in the instrumental activities of daily living (laundry,

etc.) as a subgroup variable, reporting no differences.

Nursing Home Placement.--The final subgroup variable used

in these studies was the patient's placement in a nursing home during

28

the study period. Skellie et al. found no difference in the number
of patients who survived until follow-up but did find that nursing
home service recipients in the experimental group survived a greater
number of days. Blenkner et al. found a difference for those subjects
who did spend time in nursing homes, with the experimental group
having a higher mortality rate than the control, in line with the

direction of the other findings in that study.

Subgroup Results Summary.--0ne could conclude from these
subgroup results that certain of the variables included in these
studies are more important than others in defining subgroups of sub-
jects that show different mortality effects from community-based
services. These variables are the subject's age, race, living
arrangements, AOL, and use of nursing homes. In general, the sub-
jects that were likely to have lower mortality rates in the experi-
mental conditions were those who were younger, white, not living
alone, with initially high levels or low levels of physical function-
ing in ADL. The Blenkner et al. study found that the subjects who
were likely to have a higher mortality rate in the experimental
condition were younger patients that had been admitted to nursing

homes during the study period.

Summary and Rationale
Higher survival rates have not been seen as a realistic goal
for any community—based service program for chronically-ill elderly
populations. The research studies evaluating the effectiveness of

home care services that have reported data on patient survival have

 

29

often done so more as a way of tracking subject loss than because of
any real expectation that this type of intervention could affect
patient survival. Improved physical function is even often seen as
an unrealistically high goal and a slower rate of deterioration,
avoidance or postponement of institutionalization, and improved
patient and/or family morale are often the actual stated goals. The
studies reviewed above very seldom found that significantly more
experimental than control group subjects achieved even these goals.
The fact that six of the fourteen studies above reported higher sur-
vival rates in the service groups--and that one reported lower rates
in the service group-~is thus quite significant. A recent government
report designed to “help frame policy deliberations regarding long-
term care" (Health Care Financing Administration, 1981, p. iii)
concluded that "community-based services appear to have a positive
impact on survival rates" (p. 46), citing the Bryant et al., Skellie
et al., and Neissert et al. work. This strong interpretation of the
literature in this type of report illustrates the need for further
research to help clarify the relationship of community-based services
to survival, and the policy significance of that research.

An intensive analysis of survival as an outcome variable in
data sets from other evaluations of community-based services would
seem to be useful in beginning to assess the types of services,
situations, and patients in which the effects on survival rates can
take place. There are data sets from rigorously designed experimental
studies of home care services including survival data that have not

yet been fully exploited.

30

The advantages of secondary analysis, "the reanalysis of
data for the purpose of answering the original research question with
better statistical techniques or answering new questions with old
data" (Glass, 1976, p. 3), have been explored by Boruch and Reis
(1980), Bryant and Nortman (1978), Cook (1974), and, in the area of
long-term care research, by the Inter-agency Statistical Committee
on Long-Term Care for the Elderly (1980). The use of secondary
analysis is an especially cost-effective research strategy in these
times of increasing concern over patient privacy and fiscal con-
straints.

This dissertation will be conducted using data previously
collected in an experimental study of home care services described
in Papsidero, Katz, Kroger, and Akpom (1979). This data set has
several features which make an intensive analysis of survival data
especially worthwhile. First, there are several characteristics of
the study that would seem to allow a reasonable assessment of the
benefits of home care services. The study was a true experiment with
random assignment of a large number of subjects. These 935 subjects
were followed in regularly scheduled assessments for a period of up
to 24 months using a large number of carefully developed measures
with a long history of use. Extensive administrative procedures were
instituted to ensure data quality.

A second feature of this data set that supports its use in
secondary analysis is the availability of documentation on study
procedures and the data set itself. The unavailability or incompre-

hensibility of documentation on the studies of interest has been cited

31

as a major problem in secondary analysis (Hedrick, Boruch, and

Ross, 1978). In contrast, voluminous records are available on the
Papsidero et a1. study. Funding proposals, early progress reports,
interviewers manuals, coders manuals, internal memos, minutes of
meetings, and the actual data collection forms for each patient are
all available locally, some on microfilm for easy access. The
availability and interest of the original principal investigators

and other staff members also helps assure access to information about
study procedures, treatments, measures, etc.

A third rationale for this analysis is the opportunity to
apply alternative multivariate analytic approaches to the data. The
original analysis of the data set in the Papsidero et a1. study
reported only one analysis of survival data. The chi-square per-
formed on differences in survival rates between groups was not signi-
ficant. Papsidero et al. report that the chi-square test was selected
for this analysis to provide data comparable to an earlier study
(Katz, Ford, Downs, Adams, and Rusby, 1972), and that more advanced
multivariate techniques were being explored (p. 74). To date, the
survival data have not been reanalyzed. Further opportunities for
fruitful reanalysis stem from the fact that the Papsidero et a1.
analysis included only data from the first 12 months of the 24-month
follow-up period, and only one of the two control groups.

This analysis can take advantage of the large number of
measures of the subject's demographics and health status at intake
used in the Papsidero et al. study. These measures include those

used in the twelve studies reviewed above to form subgroups of

32

subjects and assess the types of subjects who were most likely to
have significantly different survival rates. The present study will
go beyond the univariate analysis reported in the studies above to
examine the joint relationship of these variables and home care use
with survival.

This study can also take advantage of several features of the
data set to apply alternative analytic approaches to a problem
encountered in the course of the Papsidero et al. study. After
originally agreeing to be in the study, 60% of the subjects assigned
to the experimental treatment group subsequently found themselves
unable or unwilling to participate in the treatment. These patients
received no actual home care visits or only one such visit and were
considered non-service users in the present study. The non-use of
services by experimental group subjects is a common concern in pro-
gram evaluation studies conducted in "real world" field settings.

It may be an especially serious problem in studies of community-based
services. Applebaum et al., reviewed above, found that 25% of their
experimental group subjects did not use services. Neissert et al.

_ found that 25% of the day care study subjects, 20% of the homemaker
study subjects, and 49% of the homemaker plus day care study subjects
did not use the assigned services. Gerson and Hughes (1976), in a
study of post-hospital home care for surgical and short-term medical
diagnoses, found that 56% of the experimental group patients did not
use the home care services.

Dunlop (1980) cites the non-use of services in the Neissert

et al. studies as possible evidence of a "natural" limitation on the

33

demand for these services. Barney, in a 1977 article entitled "The
Prerogative of Choice in Long-Term Care", discusses the difficulties
found in reaching the frail chronically-ill elderly needing these
programs in spite of massive outreach efforts. Many of the elderly
avoid the health and social services available to them because of a
perceived connection with charity or welfare; and concern over loss
of privacy, loss of independence and possible institutionalization.
The patients, families and private physicians can also be suspicious
of outside services, feeling that the offer of services reflects
badly on their own treatment of the patient or will usurp their posi-
tions.

There are several analytic approaches that can be taken when
a large percent of the experimental group patients refuse the treat-
ment. The first is to compare the outcomes of all subjects assigned
to the experimental services, whether they used them or not, with
those of the total control group. This approach, the first of those
to be used in the study, is the most conservative as the inclusion
of large numbers of subjects who did not use the services dilutes
their effect. The second approach, that most commonly used in the
studies that attempted to deal with the problem, compares the out-
comes of those experimental group subjects using the services with
those of the total control group. This approach compares the experi-
mental group service users with a larger group of subjects that
likely contains many subjects who would not have used the services
if they had been offered to them and who are likely to differ from

the service users in important respects.

34

A third approach, that to be used in this study, attempts to
achieve greater precision through comparing the experimental group
service users with a group of control group subjects who are as
similar as possible to the service users in the demographic and health
status characteristics measured at intake to the study. The oppor-
tunity to evaluate the use of several approaches to this comon
problem of service refusal should serve as a methodological contri-
bution to the field.

To summarize, in light of the findings from the twelve
studies reviewed above, the presence of unanalyzed study data, and
the availability of multi-stage multivariate analytic approaches not
used in the original analysis, further analysis of this data set that
required five years and two and a one-half million dollars to collect

is clearly warranted.

Research Questions

The major research question to be studied is whether there
is an association between home care services and survival. Several
different analytic approaches to this question will be used. First,
several different methods will be used for forming the groups of
subjects whose survival will be compared. The first comparison will
be the true experimental test of the research question. All sub-
jects assigned to the experimental group will be compared to all
subjects assigned to the control group.

The fact that many of those assigned to the experimental

group did not actually use the home care services indicates that a

35

quasi-experimental approach could contribute to the understanding of
the research questions. One extremely useful feature of the Papsidero
et al. study was the use of many different measures of the subjects'
characteristics at intake into the study. It is expected that these
data will allow the formation of an equation predicting use of home
care services in the experimental group. This equation will then be
applied to the control group, resulting in the identification of a
smaller group of control group subjects who are more comparable to
the experimental group service users at intake into the study. A
comparison of survival will then be made of the experimental group
services users and the "user-like" control group subjects.

Another approach to the association of the home care services
and survival concerns the intensity of service use. The experimental
subjects who did use the home care services differed in the number
of home visits they received. Survival will therefore be analyzed
for these experimental group service users as a function of the
number of visits received.

Still another approach will be used to obtain a more precise
estimate of the relationship between home care services and survival.
Measures of the subjects' characteristics at intake to the study will
be used as predictors or covariates in some analyses.

Finally, survival will be operationalized in two ways, to
be called survivorship and length of survival. Survivorship is the
simple dichotomous variable assessing whether the person was still
alive at the end of the study. In this operationalization, a subject

who dies in the first week of the study is counted the same as a

36

subject who dies two years later, a week before the end of the study.
In a long-term follow-up study, the assessment of survival should
also examine the length of survival of those people that do die
during the study period.

Combinations of all the above approaches will yield many
different but related tests of the association between home care
services and survival.

One other subsidiary research question will be addressed in
this study. The twelve research studies reviewed above found many
significant differences in survival rates for subgroups of patients,
indicating the types of patients for whom community-based services
seem to have the greatest potential survival effects. In this study,
exploratory tests of the interactions among subject characteristics
and home care services in their relationship with survival will be

conducted.

CHAPTER II

METHODS
Subjects and Setting
The Papsidero et a1. (1979) study, known as the chronic
disease module study, was conducted in Michigan between 1973 and
1977. All persons who were either patients in selected ambulatory
care facilities or who were about to be discharged from selected
hospitals were screened for eligibility for referral to the project
by personnel of the referring facilities. Table 2 presents the five
locations in which the home care service teams, called chronic
disease modules, were established, the sources of patients in each
location, and the number of patients screened in each site, total-
ing 18,638. Patients who met the following criteria were considered
eligible for the study:
1. forty-five years of age or older,
2. discharged to a non-institutional setting within
geographic access to module service unit from
selected hospitals in area or living in a non-
institutional setting within geographic access to
module service,
3. in need of assistance for at least 3 months with
respect to either the activities of daily living,
(bathing, dressing, toileting, transfer, continence,
or feeding), cardiopulmonary condition or arthritis,
4. not in need of skilled nursing service, 24-hour-a-

day supervision or on kidney dialysis (Papsidero
et al., p. 28).

37

38

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39

Not all patients found to be eligible for the study were
asked to participate. Various times during the study were designated
as "non-sampling" periods where no new patients could be admitted
to the study because the service modules were serving the number of
patients that had been set as the maximum allowable caseload.
Patients screened in during these times were not allowed to partici-
pate. Other patients refused study participation when they were
contained. No figures are available on the number of patients in
these categories.

0f the eligible patients who were contacted, 1,183 agreed to
take part in the study. Patients admitted during the first three
months at each site were used to test interview and treatment pro-
cedures and were termed the baseline subjects. These 249 subjects
were eliminated from the present sample as not being comparable to
the later subjects in data collection or service procedures. The

beginning sample to be used in the present study is thus 934 subjects.

Design

Subjects were assigned randomly to either the experimental
treatment group or to a no-treatment control group, stratifying on
age and sex. The treatment group was offered the experimental home
care services while the control group was not offered these services
but were not restrained from access to any services they were nor-
mally eligible for in their communities. The modules were phased in
over a four-year period, and all modules continued to operate until

the end of the study. The study report indicated that Grand Rapids

40

served patients for 35 months, Cass County for 30 months, Gratiot
County for 39 months, Saginaw for 22 months, and Manistee for 18
months. With the exception of one group, subjects were assessed at
their intake into the study and at 6 month intervals thereafter until
the end of the data collection period. At each site, the data col-
lection period ended before some subjects who entered the study
toward the end of the collection period were able to have their
twelve-months assessments, though all were in the study at least six
months. The group of subjects that did not follow the usual inter-
view schedule was in Grand Rapids, the first module to be established.
To reduce costs by reducing the number of subjects who would have

to be interviewed every six months over the several years of the
project, the subjects at Grand Rapids were assigned randomly to
either the experimental group or one of two control groups. The
"concurrent“ control group was interviewed following the regular
schedule while the ”final" control group was interviewed only at
intake, at six months, and at the end of the study period which was
twelve, eighteen, or twenty-four months, depending on when a person
entered the study. These sixty final control group patients were
not included in the Papsidero et a1. (1979) analysis, as that study
used only the six and twelve-month follow-ups, and the final control
group did not have the twelve-month interview. Data on patient
deaths were collected throughout the study and up to 15 months after

the end of the regular data collection period.

41

Service Delivery Procedures

The home care services were delivered by a newly developed
type of paraprofessional provider, termed a health assistant, working
with an interdisciplinary team consisting of a physician and a nurse
or social worker. One team, or module, was set up in each of the
five study sites. The characteristics of each module and host agency
in which it was established are described as follows:

The Grand Rapids module was set up in a general care acute
hospital. The module physician was the medical director of the
family-oriented primary care clinic at the hospital where the module
was located. A Master's level social worker was the other module
professional. The module health assistants included one with partial
prior training as a licensed practical nurse and one who had completed
two years of college.

The Cass County module was established in the county health
department which was already a certified home care provider. The
members of the team included a local physician in private group
practice, a Master's level public health nurse, a health assistant
who was also a licensed practical nurse, and a health assistant who
had previously been a nurse's aide.

The Gratiot County module was housed in an ambulatory clinic
in this rural area. The team included the physician of the family
health center where the module was located, a Master's level nurse,
who was later replaced by a Bachelor's level social worker who had

extensive experience in rehabilitation, and the health assistants.

42

Both of these health assistants had B.A. degrees, one in psychology
and one in sociology.

The Saginaw module was set up in an ambulatory clinic. The
module professionals were a registered nurse and a family physician
in private practice who had formerly been associated with the clinic
where the module was located. Both of the health assistants had had
training in licensed practical nurse programs, and both spoke Spanish.

The module in Manistee was first set up in a clinic in a
housing unit for the elderly and subsequently moved to the county
medical care facility. The team members included a physician who
was chief of staff at a local hospital, a nurse with rehabilitation
expertise, and two health assistants. One health assistant was a
licensed practical nurse, and the other had previously received some
practical nurse training.

The teams met at regular intervals to identify patient prob-
lems, prepare a care plan, and define service activities. The roles
of the team members were outlined as follows by Papsidero et al.:
(1) Physician

(a) Assessment
Evaluated adequacy of medical information.
Relayed orders for medications and treatment
regimen from attending physician.
Assessed with social worker or nurse the behav-
ioral skills required for medical management.
Assessed the type of instruction necessary for
family members or others responsible for care.

. Discussed general condition of the ill person
and assisted in developing a problem list.

meN-H

(b) Management

43

1. Provided information on disease condition, under-
lying physiology, effect of care on prognosis,
and secondary prevention.

2. Gave medical approval of team proposal for care
and management.

(c) Referral

1. Evaluated any specialized health care needs in
management of the disease and referred to appropriate
medical channels.

(d) Follow-up/Follow-through

1. Provided continuing channel of communication to
specialized medical referral to assess adequacy
of referral care.

(2) Nurse or Social Worker
(a) Assessment

1. Performed initial assessment of ill person.

2. Assisted in team assessment and understanding of
significant social, emotional, and economic factors
related to person's care.

3. Assisted in organizing person's module service
record for continuing assessment of the case manage-
ment.

(b) Management

1. Initiated introduction of the module to the person

and family.

Assumed primary responsibility in developing problem

list and management plan.

Provided expertise in rehabilitation nursing techni-

ques and in interpretation of home care nursing orders.

. Offered ongoing supervision of health assistants'
activities.

450)“)

(c) Referral
1. Relayed knowledge regarding community resources
(health, financial, recreational, education) available
to person and family; referred to appropriate agency.
(d) Follow-up/Follow-through

l. Assurred that referral process was adequately completed;
provided feedback on success of that process.

44

(3) Health Assistant

(a) Assessment

(b)

(c)

(d)

1. Provided ongoing assessment of person during periodic
home care visits; also assisted family situation,
social and economic setting, and any other factors
affecting a person's progress and care.

2. Provided assessment of any family members that needed
professional care.

Management

1. Relayed information about home visits to the team in
the Problem Oriented Medical Record format to use in
matching person's needs and resources in home environ-
ment to the other team member's skills.

2 Helped in preparation of health assistant problem-
oriented task list.

3. Performed the bulk of direct service to person and
family in the home.

4. Educated person and family for self-management.

5. Provided some transportation for person.

Referral

1. Assisted in referrals to other agencies (social,

educational, health care agencies according to
person's assessed need).

Follow-up/Follow-through

1.

Through follow-up home visits, provided continued
feedback on success of referral programs in meeting
the specific needs of persons (p. 45-47).

As the health assistants were the primary providers of direct

services to the patients, it is important to present a further

description of their duties and training.

1.

Services Performed by the Health Assistant

The activities of the health assistant represent the
extension of selected skills of the physician, nurse,
social worker, and rehabilitation therapists, such as
occupational therapists, physical therapists, speech
therapists, and audiologists. The objectives of health
assistant activities pertaining to rehabilitation were
to assist the patient to achieve and maintain an optimal

45

level of physical functioning and to prevent, as far

as possible, secondary complications of the disease
process. In general, the rehabilitation functions
focused on activities of daily living: bathing, dress-
ing, going to the toilet, walking, feeding, etc. The
health assistant provided or taught others to provide
therapeutic exercises to increase muscular strength and
coordination so that the person was better able to
carry out activities of daily living and prevent or
delay physical deterioration. The health assistant
also performed household management tasks intended to
provide a safe and healthful home environment and
increase the person's mobility--as for example, physical
modification of the home to accommodate loss of physical
functioning, and light housekeeping as necessary until
other more permanent arrangements could be made.

Other health assistant activities were designed to pro-
mote social functioning and were also varied and indivi-
dualized. A therapeutic relationship was established
with the person and family that enabled improved communi-
cation of concerns, social problems, and conflicts that
may have interfered with the person's care and rehabili-
tation. Discussion about the disease process was faci-
litated to increase the patient's understanding of and
adaptation to disease, disability, and the care process.
Support in the terminal stages of the disease was pro-
vided when necessary. In addition, the health assistant
aided the patient in developing greater social awareness
by direct interaction, helped the patient and family
participate in community activities and find productive,
enjoyable ways to use leisure time. The health assistant
sought to alleviate economic problems by suitable refer-
rals and made arrangements for housing if the patient's
living situation was unsafe or inadequate for the person's
or family's needs.

Training for Servide

The goal of the instructional program for health assis-
tants was to provide a systematic learning experience by
which specialized knowledge, attitudes, and skills were
acquired. Thus, the health assistants were prepared to
(a) provide assistance in selected patient care manage-
ment functions in the home, (b) perform on-going assess-
ment of patient functioning, and (c) help the chronically
ill individual and his/her family to cope realistically
with health-related and social problems.

46

The instructional program for health assistants was
implemented in two phases over a nine-month, three-
quarter period. Phase I, the "pre-service" phase,
required health assistants to enroll in selected
introductory community college courses. These courses
provided instruction in basic medical terminology,
anatomy, physiology, nursing, and other topics considered
to be consistent with overall objectives. Phase II, the
“in-service" phase, provided a specialized field experi-
ence offered by the faculty of a Cadre Training Unit, a
group organized as a training and continuing care module.
This phase required the health assistant to increase
knowledge and skills about care of the chronically ill
and to demonstrate these in the home under supervision.
Phase I and Phase II overlapped midway during the nine-
month period. Upon successful completion of the course
of study, health assistants were granted a certificate.

A third phase of the educational program began when the
health assistants and module professionals started a
three~month period of service in the host agency, as a
team. Team performance as well as individual performance
were assessed. A program of continuing orientation in
which the educational processes described above were
reinforced and evaluated was then initiated and continued
through the study period.

As a parallel activity, the professional development
seminars for health care professionals were also imple-
mented during the nine-month period, and required
increasing time commitment up to eight hours a week.

The physicians, nurses, and social workers selected

for each module attended seminars related to professional
problem-solving, team functioning, and the pattern and
policies of module service (Papsidero et al., 1979,

p. 49-50).

Papsidero et a1. (1979) present some data describing the
health assistant's home visits. During a thirteen month sampling
period the patients received an average of 3.2 visits per month
lasting an average of 46 minutes each (derived from Figure 5.1,
Papsidero et al., p. 55). Health assistants completed activity forms
describing their services in the home. Table 3 presents the percent

of home visit time spent on various activities.

47

TABLE 3

Percent of Home Visit Time in Various Activities

 

 

Service Activity in the Home %
Problem Assessment 41
Education of Patient 7
Education of Family 3
Direct Assistance 29
Transportation of Patient 6
Referral 1
Consultation 2
Other Care-Related Activity 10

Other Activity

 

(Adapted from Table 5.2, Papsidero et al., 1979, p. 56.)

48

Data Collection Procedures

The research was directed by a centrally-based team composed
of the project director, a senior research analyst, two research
associates, an economist, a cost analyst, a health educator, a nurse
practitioner, a nurse educator, a social work educator, a physician,
a statistician, four research assistants, three data coders, two
computer programmers, two keypunch operators, two secretaries, and
a field supervisor.

Two interviewers and a data controller were recruited in each
of the five module areas. Interviewers were women between the ages
of twenty-three and fifty-four. Most were married and college-
educated. They were trained and supervised by persons with bachelor's
degrees and with experience in health research interviewing. Inter-
viewers had 40 hours of training consisting of seminar discussions
about chronic illness and aging, sessions on the principles of
research interviewing, and role playing sessions to practice inter-
viewing.

The initial contact of the trained interviewer was always
face-to-face, and in the case of the hospitalized patients, was made
before discharge, whenever possible. Two-thirds of the initial
interviews were obtained within 2 weeks before and after the sub-
jects' entry into the study and about one half of the six and twelve
month interviews were obtained within two weeks before or after the
date scheduled for the evaluation (Papsidero et al., 1979, p. 35).
Delays were most often due to temporary acute illness of the subject,

poor roads, poor weather conditions, or the subject's temporary

49

residence outside the module area. Three attempts were to be made
to complete interviews as scheduled.

All interviews after the initial one were conducted in the
home. Telephone contacts were made only when requested by the parti-
cipant. The exact wording and probes were specified in the inter-
view protocols, and data items were precoded.

The interviewers were separated geographically and adminis-
tratively from the service personnel, and their involvement in service
was prohibited. Interviewers were not allowed access to information
through which they could learn whether a participant was in the
experimental or the control group. To provide continuity and main-
tain rapport, an attempt was made to have the same interviewer for
all interviews for any one subject. Two-thirds of the participants
had the same interviewer throughout the entire study (Papsidero
et al., 1979, p. 34).

The field interviewers and data controllers from all sites
attended meetings at Michigan State University on a regular basis.
The evaluation coordinator instructed data coders to report to her
any deviation in the forms received from the sites, which would
then be reported.

All interview forms were edited by interview supervisors.
Data were coded and checked for internal consistency by a
central data controller and two coders. In addition, a

10% sample of all coded interviews were coded by both

coders. The two coders agreed in 19,665 out of 19,780

codes, representing better than 99% agreement in this
reliability study.

Data were entered onto punch cards and run through a cleaning

and verifying program. Only about 0.05% of the 713,664 codes
required correction of errors and inconsistencies. Data were

50

stored in both a permanent computer disc file and a back-up
magnetic tape file to guard against loss (Papsidero et al.,
1979, p. 35).

Table 4 represents the availability of data on patient out-
comes at different follow-up time periods, i.e., the number of
patients who were known to be alive or dead at each point following
their entering into the study. Of the 934 patients in the original
sample, 54 did not complete the initial interview and were thus
missing the majority of the study measures. A further five patients
could not be located at the six months interview and thus have no
outcome data available. The total number of patients included in
later analyses is therefore 875.

Table 4 indicates that outcome status (dead or alive) is
known for a total of 875 patients at six months, for a total of 627
patients at twelve months, for a total of 290 patients at eighteen
months, and for a total of 247 patients at twenty-four months.

The importance of these figures for the present study is
centered around the question of possible bias in the knowledge of
outcome status between the experimental and control comparison groups.
It could be, for example, that those persons receiving services in
the experimental group would be less likely to refuse the interviews
than those in the control group. These persons might, for example,
be more interested in their health and willing to discuss it, or of
a more generally acquiescent frame of mind. In that case, it could
be that there was more opportunity to learn about the deaths of
patients in the experimental group than in the control group. In

this situation, it could appear that there were a greater number of

51

 

 

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52

deaths in the experimental group than in the control group, and that
the services were harmful, when the number of deaths were actually
equal--or even greater in the control group. It should be noted that
this source of bias may be less problematic because, as noted earlier,
the interviews were not the only source of data on patient deaths.
The newspapers in all the module sites were examined throughout the
study period for obituaries of all study subjects, even after they
had refused or otherwise could not be contacted for interviews.

The extent of bias was examined by comparing the figures on
outcome data availability for the experimental and control groups.
For the purpose of this analysis, only the number of subjects who
were contacted for interviews at each follow-up period were compared,
to avoid confounding this analysis with the later comparisons of
survival rates. A variable was created which gives, for each patient,
the last interview at which the person was contacted: initial, six
twelve, eighteen, or twenty-four months. When this variable was com-
pared for the experimental and control groups, a chi-square of 10
resulted (df = 4,.2 = .038). In contrast to what might have been
expected, the control group subjects were more likely than the experi-
mental subjects to have completed later interviews. This could indi-
cate that there were more opportunities to learn of control group
than experimental group deaths, thus possibly making the treatment
look better than it really was.

Further investigation revealed that the higher percentage of
later control group interviews was concentrated in the "final" con-

trol group. This is the group of 56 patients who were randomly

53

assigned to be interviewed only three times during the study:
initial, six months, and a "final" interview at the end of the study.
Apparently because of their special status, arrangements were made'
such that these final interviews were scheduled and completed for
all of these patients before the end of the study. When the time

of the last interview was compared for the experimental patients and
all control group patients except the 56 "final" control group
patients, the resulting chi-square was only 2.8 (df = 4, n.s.). It
can be noted at this point that in order to assess the influence of
this possible source of bias on the results, the major outcome
analyses described below were rerun without the "final" control group

patients, with no change in the results.

Measures

Four types of measures were needed for the present study.
First, assessments of the patient's status at intake into the study
were needed to be used as predictors, along with service use, in some
of the outcome analyses and to describe the subgroups of experimental
group service users and control group "user-like" subjects to be
compared in some outcome analyses. For presentation purposes, the
measures of intake status are divided into three groups: demographic,
physical health status, and psychosocial health status.

Next, measures of the study process at the time of the initial
interview were included as possibly important predictors of the
patient's acceptance or non-acceptance of service. A measure of the

treatment process, the number of home visits received by the patient,

54

was included for use in some outcome analyses. Finally, two measures
of survival, survivorship and length of survival, were included as
outcome measures.

Some measures used in the Papsidero et al. study were not
used here because they were not collected in the initial interview
(e.g., income, mobility, walking) or were not considered relevant
(e.g., identity of coder). Other measures were eliminated when
examination of frequency distributions revealed that they duplicated
other variables (e.g., outpatient or inpatient status at initial
interview and place of interview) or that the frequency or variance
was extremely low (e.g., relationship of the third other person
present at the interview to the patient).

At this point also an examination was made of the pattern of
missing data by patient. As reported earlier, the 59 patients missing
both the initial and six months interviews were eliminated from the
analysis. Missing data items on the initial interview for the remain-
ing 875 patients were widely scattered across data items. The mean
values of the items were substituted for any missing values as the
most conservative procedure.

In the next stage of the analysis, some study process vari-
ables were eliminated when they showed extremely low correlations
with service use in the initial analyses used to classify experimental
group service users, to be described in the Results section. The list
of measures to be discussed here is that used in the final discrimi-
nant function analysis used to predict service use. At a later stage

in the analysis, to be described later hithissection, the number of

55

intake status variables was reduced further for more efficient use
as predictors in the outcome analysis.

The measures used in this study are listed in Table 5 and
presented in more detail in Appendix A. The major data collection
instruments are presented in Appendix B. The references in Table 5
give the background and procedures for established measures. Recent
reviews have demonstrated the widespread use of many of these measures
(Katz, Hedrick, and Henderson, 1979; Hedrick, Katz, and Stroud, l980/
1981; Hedrick, Papsidero, and Maynard, 1981). Many measures had been
used by members of the Papsidero et a1. research team in an earlier
experimental study of home care services (Katz et al., 1972) and
were chosen in part because of "the demonstrated utility of the
measures in that study, and the desire to compare findings between
the two studies" (Papsidero et al., p. 30).

Appendix A presents the name of the measure with the vari-
able label used in the analysis in parentheses. A description of
the measure and a list of the variables included in an index or
composite measure is included where appropriate. Next, the coding
and range or frequency distribution and the dummy coding used for
several variables is given. Finally, the source of the measure is
presented. Some measures were obtained from the forms used to screen
patients into the study. The majority of the measures were obtained
from the form used to record the face to face interview with each
patient. This is indicated by an "I" in the Data Source column.

The numbers indicate the number of the question or questions on the

form from which the data were obtained. The measures can now be

56

TABLE 5

Principal Measures

 

DEMOGRAPHIC

Age

Sex

Ethnic Group

Marital Status

Index gf Economic Dependence (Staff of Benjamin Rose Hospital,
1961

Socio-Economic Status of the Aged (Bloom, 1972)

Type of Residence

Residence Stability

Number of Cohabitants

Identity of Cohabitants (11 variables)

Number of Non-Working Adult Cohabitants

Relationship of Principal Care Giver to Patient

Residence of Principal Care Giver

PHYSICAL HEALTH STATUS

 

Diagnostic Risk

Severity of Illness

Morbidity

Number of Physical Screening Criteria Satisfied for Entry
Into Study

Index of Independence in the Activities of Daily Living
(Staff of Benjamin Rose Hospital, 1958, 1959; Katz et al.,
1963, 1970, 1976)

Screening Source

Physician (77 variables)

PSYCHOSOCIAL HEALTH STATUS

Social Role Functioning (Spitzer, Gibbon, and Endicott, 1971)

Contentment (Bloom and Blenkner, 1970)

Mental Status Questionnaire (Kahn et al., 1958, 1960, 1961,
1962; Pollack et al., 1958)

Raven Coloured Progressive Matrices (Raven, 1962)

STUDY PROCESS
Site

Interviewer (10 variables)
Location of Interview

57

TABLE 5 (Continued)

TREATMENT PROCESS

Number of Home Visits Received

OUTCOME

Survivorship
Length of Survival

58

discussed in more detail in order as they appear in Table 5 and

Appendix A.

Demographic Measures

Age and sex were both obtained from the screening form and
are self-explanatory. Ethnic group is classified here as white,
black, or other language. This last group is people who reported
that they speak a language besides English with friends and/or rela-
tives. Marital status was dichotomized with those widowed, divorced
or separated, or never married coded as not married. The next
measure is the Index of Economic Dependence, first developed by mem-
bers of the research team in 1961 (Staff of Benjamin Rose Hospital,
1961) and used in the earlier study of home care (Katz et al., 1972).
The index combines measures of employment status, home ownership,
and public and private agency support into a five-point scale from
most to least financia1.independence.

The second index used, the Socio-Economic Status of the Aged
scale, covers different areas, combining education, occupation, and
a source of income scale. This scale was developed based on Bloom
(1972). The index is also a five point scale, from highest to lowest
status. Education and occupation are scored and weighted using the
Hollingshead (1957) system. The source of income scale determines
the source from which the person receives the most income and bases
the score on the usual amount of income, prestige, power, and inde-
pendence provided by that income source. The seven sources of income

range from the highest status source of "annuities, insurance,

59

interest, dividends, rentals, etc." through salary; pensions;
"withdrawals from savings, cashing bonds, selling things you own,"
gifts, loans, or private social agencies; and public assistance; to
"no regular income" as the lowest status score.

The next measure, type of residence, was dichotomized so that
people were coded as living in their own or spouse's homes, or in
any other type of residence. Residence stability was measured on a
six point scale with one end point being people who had lived in
their present residence for ten years or more and the other being
people who were moving to their residence at the time of the inter-
view.

The next measures concern the people the patient lives with,
or cohabitants. The first variable is the number of cohabitants,
which ranged from none to seven. The next eleven variables describe
the relationship of the cohabitants to the patient: wife, husband,
daughters, sons, grandchildren, siblings, other relatives, friends,
and others. Daughters and sons were further divided into younger (30
years of age or less) and older (greater than 30 years of age). This
was designed to help distinguish between family situations in which
the patient lived with dependent single younger children and those in
which the patient was living with an older child and the child's
family, a situation in which the patient was more likely to be depen-
dent.

Variables that indicated whether each cohabitant worked full-
time or not were combined into a measure of the number of non-working

adult cohabitants to serve as an index of the number of people in the

60

home who might be free to give personal care to the patient during
the day. All except fourteen patients did name someone, known as
the primary care giver (PCG), who gave them "the most help with
personal care and household tasks." The relationship of the PCG to
the patient was coded on a four point scale as spouse, child, other
relative, other. The residence of the P00, with or not with the

patient, was also determined.

Physical Health Status

The patient's primary diagnosis was identified as the diagno-
sis which led to the most recent hospital admission, or for those
patients whose entry into the study was not preceded by a hospitali-
zation, that associated with the patient's major disability, e.g.
paralysis or missing limbs. The diagnoses were first coded using
the twelve major categories of the International Code of Diseases,
adopted for Hospitals (H-ICDA) (Commission on Professional and Hospi-
tal Activities, 1968). These twelve categories were then combined
into a dichotomous measure of diagnostic risk. Patients were coded
as having either a high risk or low risk diagnosis, with high risk
diagnoses being neoplasms (cancer), diseases of the nervous system
and sense organs, and diseases of the circulatory system. Another
dichotomous categorization of diagnoses was based on assessments of
the severity of the diagnosis made by a project physician. High
severity diagnoses were defined as degenerative diseases of the
cardiovascular, renal, central nervous, and pulmonary systems; neo-

plasms; and diabetes.

61

Morbidity was measured by the number of bed disability days:
the number of days during the past two weeks spent as an inpatient
or in bed all or most of the day.

The next measure is the number of physical screening criteria
for entry into the study the patient satisfied. There were six .
criteria used: need for help with bathing; need for help with dress-
ing; need for help with walking; shortness of breath; cough or sputum;
and joint pain, stiffness, or swelling. Some patients met only one
of these while others met all six, indicating a progressively greater
number of coexisting chronic illnesses.

The major measure of physical function at entry into the
study is the Index of Independence in the Activities of Daily Living
or AOL. Papsidero et al. describe this measure:

Measures of activities of daily living, walking and mobility
had been developed and applied by the authors during more

than seventeen years. One of these, the Index of Indepen-
dence in Activities of Daily Living, is a sociobiologic
measure that ranks people according to their level of depen-
dence in six basic functions, namely; bathing, dressing, going
to toilet, transferring, continence, and feeding (Katz and
Akpom, 1976; Staff of Benjamin Rose Hospital, 1959). In a
single summary grade, the Index reflects the adequacy of a
person's organized neurological and locomotor behavior. A
particularly useful characteristic of this measure is the
behavioral relationship among the activities contained in

the scale. Its basic nature has been supported by the obser-
vation that the order in which independent functions are
regained parallels the functional development of children.

The usefulness of the measure has been demonstrated in numerous
epidemiologic studies, in surveys, and in experiments (p. 31-
32 .

The index is scored from zero to six, the number of the six
functions that the person performs independently, i.e. without

assistance or supervision from another person. The internal

62

consistency of the measure, as measured by the standard score coeffi-
cient alpha (Cronbach, 1961) is .80.

The next measure is the screening source, or the place from
which the patient was screened into the study. This was dichotomized
into acute general hospital, for those people who were hospital
inpatients at screening, and other sources, which included outpatient
clinics and public health clinics. This variable has been used as a
measure of the patients' stage of illness, with patients who were
hospitalized at intake being seen as having a condition with a more
recent onset or acute exacerbation.

The final measure in this section is the identity of the
patient's primary personal physician. This measure was included in
the study based on reports by project staff that indicated that a
major factor in patients' failing to accept project services was
opposition from their physicians who were concerned about losing their
patients to the project physician. Patients listed 183 different
physicians as their primary physicians. Physicians who were listed
by only one, two, or three study patients were eliminated, leaving
77 physicians who were listed by 4 to 36 patients.- Variables called
Physician l to Physician 77 were then constructed, each of which was
scored as 0 if the person did not have the particular physician, and

1 if the person did have this physician.

Psychosocial Health Status
Four measures of psychosocial health status are included in

this study. The first is a measure of social role functioning based

63

on Spitzer, Gibbon, and Endicott (1971). This measure is defined as
the highest level of role function the person assumed in the last
two weeks. It is measured as the greatest amount of activity the
person engaged in with his/her spouse, relatives, or friends. People
who reported doing nothing with anyone were scored lowest, followed
by people who reported doing only "a few things," followed by people
who reported doing "many things" with at least one category of person.

The next measure is a five-item scale of contentment, based
on Bloom and Blenkner (1970). The score is determied by the number
of "contented" responses given to five questions concerning happiness,
satisfaction with household arrangements, satisfaction with way of
life, worry over health, and whether "things keep getting worse for
me as I get older." The standard score coefficient alpha of the scale
is .54.

The mental status questionnaire (MSQ) assesses whether the
patient is oriented to time, place, and person. This measure has a
long history of development and use in studies of long-term care
populations and clinical settings (Kahn et al., 1958, 1960, 1961,
1962; Pollack et al., 1958). It is scored as the number of correct
answers to ten questions asking the person the month, day, year;
his/her age, month and year of birth; current location; and the cur-
rent and former Presidents of the United States. This scale has a
standard score coefficient alpha of .78.

The Raven Coloured Progressive Matrices (Raven, 1962) was

used in this and previous studies by members of the research team as

64

a measure of observation and clear thinking. Papsidero et al. report
that the test:
has been standardized for evaluation of elderly people and
has been found to correlate well with the Wechsler Adult
Intelligence Scale (Raven, 1962). The Raven test consists
of sets of multiple choice problems arranged in order of
increasing complexity. Each contains a graphic pattern from
which a segment has been removed and six possible inserts
from which the subject selects the matching insert. Since
manual dexterity and the ability to speak are not necessary,
it is very useful in testing aged and disabled people. It
also covers a range of intellectual complexity that is
appropriately discriminating of the capacities of old and
disabled people (p. 32).
The scores range from O to 18. This variable had the largest amount
of missing data in the study, as 250 people refused or were unable

to take the test, often because of poor vision.

Study Process

The first of the three study process measures used is the
geographical site. As reported earlier, chronic disease service
modules and data collection units were set up separately in five
sites around Michigan: Grand Rapids, Cass County, Gratiot County,
Saginaw, and Manistee. These five sites undoubtedly differ in rural
vs. urban character, availability of health care services, socio-
economic status of the residents, ethnic group mix, etc. Also, in
spite of the great attention paid in the study to standardizing
patient care and data collection procedures across sites, the inevi-
table differences between sites in these procedures could also affect
patient outcomes. Site was thus included in the analyses as four

dichotomous dummy variables.

65

The next measure is the identity of the interviewer who
conducted the initial interview with the patient. This was felt to
have a potential effect on the patient's decision to accept or not
accept home care services. Only those interviewers who interviewed
more than twelve patients were included, resulting in ten inter-
viewers who interviewed from 13 to 279 patients each. The resulting
ten variables, Interviewer 1 to Interviewer 10, were scored as 0 if
the person did not have this particular interviewer and 1 if the
person did.

The final study process measure is the location in which the
initial interview took place, dichotomized as hospital or other.
This measure was also felt to be a potential influence on the

patient's likelihood of accepting services.

Treatment Process

The intensity of home care service received by the experi-
mental group subjects who received home care visits is the number of
such visits they received over the study period. This measure is
felt to be a reasonable basic indicator of service intensity which

is useful in clarifying the patient outcome analyses performed.

Outcome

Information about patients' deaths was obtained at the time
of the scheduled interviews, from the study service providers, and
from an established procedure of checking the obituaries in the news-
papers of all the locations of the modules. Obituaries were checked

for all patients, including those who refused services, those who

66

refused interviews, and those who refused both. These obituaries
were continued to be checked for a period of 15 months after the end
of the follow-up interviews. Death certificates were obtained for
all subjects who died to verify information about the date and cir-
cumstances of death.

The information on death was then used to construct two
measures of survival: survivorship and length of survival. Survivor-
ship is dichotomized as survival or non-survival at the end of the
study period for each patient. Length of survival is the number of
days from entry into the study until death, for those patients who
did die during the study period.

Data Reduction

As indicated at the beginning of the measures section, the
complete list of demographic, physical and psychosocial health status,
and study process measures just described are those that were used
in the discriminant function analyses to obtain the greatest amount
of predictive power in classifying subjects as service users or non-
users. The variables were not severely reduced in number or clustered,
a priori, in order to obtain the maximum predictive power available
in the data set. Since the purpose of the analysis was not to explain
service use, such an empirical approach could be supported. This is
not the case with the outcome analyses, however. The purpose of
including measures of patient status at intake in the outcome analyses
is to help obtain more precise estimates of the relationship of ser-

vice use to survival by including a smaller number of measures as

67

predictors in the analyses. An efficient use of these measures in
Table 5 in the outcome analysis required a reduction of their number.
Rational considerations were used to select the predictors
for the outcome analyses. The major intent was to include demographic
measures, physical health status measures, and psychosocial health
status measures. The study process measures such as the identity of
the interviewer and the location of the interview, as well as measures
such as the identity of the patient's physician, while included in
the discriminant function as predictors of service use, were not seen
as important predictors of survival and were therefore eliminated.
Beginning with the demographic measures, the thirteen measures
used as predictors in the outcome analyses can be described. Age
and sex were used as presented in Appendix A. The measure of ethnic
group presented in Appendix A as two dummy variables categorizing
patients as black, white, or other language was simplified into one
dichotomous variable by combining white and other language. The
Socio-Economic Status of the Aged measure was used as presented in
Appendix A. The multiple measures in Appendix A describing the
patient's living arrangements were represented by one measure derived
from Katz et al. (1972) describing the type of person(s), if any,
with whom the patient lived:

u—l
O

with spouse
without spouse, with child
without spouse or child, with other relatives

without relatives, with others

0'1 # (A) N
o o 0 0

alone.

68

All six of the measures of the patient's physical health
status, excepting the identity of the physician, were used as these
variables were thought to be especially important potential predictors
of survival. As measures of psychosocial health status, the social
role functioning score and the mental status questionnaire were used.
The low reliability of the contentment scale and large amount of
missing data on the Raven scale weighed against their use. To sum-
marize, the thirteen measures used as covariates in the later outcome
analyses are age: sex, ethnic group, socio-economic status, living
arrangements, diagnostic risk, severity of illness, morbidity, number
of physical screening criteria met, index of independence in the
activities of daily living, screening source, social role functioning,

and mental status questionnaire score.

CHAPTER III

RESULTS

A clear explication of the relationships between subject
characteristics, home care services, and survival required that a
multi-stage analytic approach be used in this study. The outcome
analyses were repeated in both experimental and quasi-experimental
designs using different operationalizations of survival, different
operationalizations of the use of home care services, and different
techniques for incorporating the subject characteristic variables
into the analysis. The pattern of results from these analyses, that
is, the extent to which the results converge, was examined to obtain
the most precise and generalizable estimates of the predictive power
of the factors of interest. This multi-stage analytic approach has
been advocated by Boruch (1978), Boruch and Rindskopf (1977), and
Boruch and Gomez (1977), and applied in the Weissert et al. (1979)
study reviewed earlier. This data set allows at least 12 separate
but related tests of the basic research question. The basic features
of these analyses are presented schematically in Table 6. The numbers
in the cells of the table refer to the number of the analysis,

described below.

69

70

TABLE 6
Data Analysis Plan

 

Without Covariates
Length of
Survivorship Survival

With Covariates
Length of
Survivorship Survival

 

Experimental
Distinction

Quasi-Experimental
Distinction

Service Intensity
(Experimental
group only)

1 2
5 6
9

3 4
7 8
10

 

71

1. Experimental Distinction
with Survivorship

Analyses 1 through 4 were comparisons of outcomes for all
patients assigned to the experimental and control groups. In the
first analysis, the crosstabulation of this experimental distinction
by survivorship, the patients' status as alive or dead by the end of
the study period, indicated that the percent of experimental group
subjects surviving was 78% (321 of 411) compared to 77% for the
control group (357 of 464) (x2 = .11, n.s.). There appeared to be
no relationship between the experimental distinction groups and sur-
vival.
2. Experimental Distinction
with Length of Survival

The next analysis used the second operationalization of the
outcome variable, the length of survival. This was measured as the
number of days survived from entry to the study by those 197 patients
who died during the study period. The length of survival ranged from
3 to 967 days for these patients. The relationship between the
experimental distinction and length of survival was marginally signi-
ficant (point biserial correlation coefficient = .12, p.= .051). The
coefficient indicates that the direction of this finding was that
being an experimental group subject was associated with living a
shorter number of days. This finding, in isolation, is not neces-
sarily evidence for a negative effect of treatment. However, if it

is supported in later analyses, it may be an important finding.

72

3. Experimental Distinction
with Survivorship with
Covariates

The next analyses were designed to obtain a more precise
estimate of the relationship of the experimental distinction and the
outcomes by attempting to control for any differences between the
groups in the status of the subjects at entry into the study. Thir-
teen measures of the subjects' demographic, physical health status,
and psychosocial health status were chosen, as described in the
Measures section, through examination of preliminary analyses of
their relationship to the outcome of survivorship and their theoreti-
cal importance. These measures were age, sex, living arrangements,
ethnic group, socioeconomic status, screening source, number of
physical screening criteria satisfied for entry into the study,
severity of illness, diagnostic risk, morbidity, social role function-
ing, activities of daily living, and mental status questionnaire
scores.

In this analysis, a regression of survivorship on the experi-
mental group variable was performed, with the 13 intake status vari-
ables entered first into the analysis, in stepwise fashion, followed
by the experimental distinction variable. The summary table for this
analysis, presented in Table 7, shows that the experimental distinc-
tion variable did not add significantly to the equation (F to enter
= .5, n.s.). The simple 5 between the treatment variable and survi-
vorship was only .013 and the partial r remained fairly constant
throughout the steps of the analysis, suggesting that the relation-

ship between the treatment groups and survivorship was independent

73

 

 

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ooo. oo.o_ oo. oo. ooo. No.~ so.o_oeoz
ooo. oo.op o_. No. oo_. oo.~ moooom oooooooo-o.oom
ooo. oo.o_ op. No. ooo. oa.~ ooooo_ooooo opom Foooom
ooo. oo.o_ o_. No. ooo. oo.o ouzoom oooooozoo
ooo. oo.o_ e_. _o. eoo. oo.o 3oz o_.oo_zo ooooooaoo Lo .oz
ooo. mo._~ N_. _o. ooo. oo.o oa.oooooomooo moooom pooooz
ooo. oo.o~ 2,. oo. “No. oo.o oooeo oooooo
ooo. oo.o~ op. oo. ooo. oo.~ mooooooooaao ooo>oo
ooo. o_.oo o_. oo. ooo. oo.~ xm_¢ o_omoooo_o
ooo. oo.oo op. om. ooo. oN.oF oo<
ooo. o~.~o op. om. ooo. h~.oN xoo
ooo. oo.oo o_. No. ooo. oo.oo mmooppo oo »o_ao>oo
ooo. oo.~m oo. oo. ooo. oo.~o oo_>oo »P_oo Lo mo.o.>.oo<
mucou_w_=m_m m Fpocm>o mm a mpowupzz mucou_wwcmom goucm on m omcmucm apno_co>

 

 

nocmgo>_>g=mw=_uo_omgo cowommemmm 0o mgossom

m m4m<h

 

74

of the other variables. This lack of moderator effects lends further
support to the finding in analysis 1 of no relationship between the
experimental distinction groups and survivorship.
4. Experimental Distinction
with Length of Survival
with Covariates

Next, the relationship between the experimental distinction
and length of survival was further analyzed in a similar regression
analysis with length of survival as the criterion and the 13 intake
status variables entered into the analysis before the experimental
distinction variable. The simple 5 between the treatment variable
and length of survival, .12, which was reported as significant in
analysis 2, was reduced to a partial r of .05 during the steps of
the analysis and the variable did not add significantly to the equa-
tion (5 to enter = .5, n.s.). It would thus seem that the relation-
ship between the experimental groups and length of survival is largely
accounted for by the linear combination of the intake status variables.
Therefore, this finding does not support any contention of negative
effects from the module treatment.
5. Quasi-experimental Classi-
fication with Survivorship

A quasi-experimental approach to the data set is indicated
by the fact that a large number of the subjects assigned to the
experimental group did not use the home care services. Boruch (1981)
recently discussed several approaches to this common situation as a

part of the analyses of the Seattle and Denver Income Maintenance

75

Experiments. In the approach used here, survival outcomes were com-
pared for two groups of patients selected from the total experimental
and control groups. These two groups are the service users: experi-
mental group patients who used the home care services, and the user-
1ike control group patients: control group patients similar to the
service users at intake to the study. A discriminant function analy-
sis was used to discriminate between service users and non-users in
the experimental group, using the demographic, physical and psycho-
social health status, and study process variables in Table 4. The
intent of this analysis was not to explain service participation,

but to find the classification function that best discriminated the
users and non-users. Since the intent was not on describing the
contribution of individual variables, multicollinearity was not a
major concern.

In a preliminary discriminant function analysis all 124
measures presented in Appendix A were included. The following
measures were found to have very small canonical discriminant func-
tion coefficients and were eliminated from the analysis at that
point: age, type of residence, residence stability, 36 of the Physi-
cian l to Physician 77 variables, and Interviewer 7. The final
function, made up of 85 variables, was highly significant with a
chi-square of 154.90, p_< .0001, and contained 34% of the variance
accounted for in service use.

The function correctly classified 77% of the experimental .
group patients as service users or non-users. As 60% of the experi-

mental subjects were non-service users, a random selection of control

76

group subjects includes, in a sense, 40% errors. Use of the discri-
minant function removes 42% of this error, i.e., (77-60)]40. There-
fore, the use of the discriminant function to choose user-like con-
trol group subjects does represent a gain in accuracy.

When the discriminant function was applied to the control
group, 149 of the 464 control group patients, or 32%, were categor-
ized as service user-like patients. This group was compared to the
experimental group service users in the following analyses.

The crosstabulation of this quasi-experimental classification
by survivorship resulted in findings quite similar to those resulting
from the comparison of the survivorship of the original experimental
and control subjects in analysis 1. Here, 77% of the experimental
subjects (128 of 166) and 75% of the control subjects (111 of 149)
survived at end of study (x2 = .17, n.s.). There appeared to be no
relationship between membership in the service user or user-like
control groups and survivorship.

6. Quasi-Experimental Classi-
fication with Length of
‘Survival

In this analysis, the relationship between the quasi-experi-
mental classification and the length of survival, for the 76 patients
from these subgroups that died during the study, was assessed. This
relationship was not significant (point biserial correlation coeffi-
cient = .16, n.s.). That is, there was no relationship between the
treatment variable and length of survival. This finding further

supports the earlier conclusion that the marginally significant

77

correlation between the experimental distinction and length of sur-
vival found in analysis 2 was due to other factors besides the
treatment.
7. Quasi-Experimental Classi-
fication with Survivorship
with Covariates

In this regression analysis, the 13 intake status variables
described earlier were entered into the analysis first, followed by
the quasi-experimental classification variable, with survivorship
as the criterion. The classification variable did not add signifi-
cantly to the equation (F to enter = .83, n.s.). The simple 5 of
.03 remained fairly constant as a partial 3 throughout the steps of
the analysis, indicating that the relationship between the classi-
fication groups and survivorship was independent of the other vari-
ables. The lack of moderator effects in this analysis lends further
support to the finding in analysis 5 of no relationship between the
classification groups and survivorship.
8. Quasi-Experimental Classi-
fication with Length of
Survival with Covariates

This next regression analysis examined the relationship
between the quasi-experimental classification and length of survival,
with the 13 intake status variables entered first into the analysis.
The classification variable did not add significantly to the equation
(5 to enter = 1.28, n.s.). The partial r changed from .16 to .05 on
one step of the analysis, and by much smaller degrees on the others.

This finding does not offer much support for the existence of any

78

moderator effects influencing any relationship between the classifi-
cation variable and length of survival.

9. Service Intensity with

Survivorship

Analyses 9 and 10 employed a new operationalization of the
treatment variable. A basic measure of the treatment process, the
intensity of the home care services received by the subjects, was
operationalized as the number of home care visits received by the
patients in the first twelve months following their entry into the
study. As subjects for whom these figures were missing or who had
received only one such visit had been placed in the non—service user
group, the number of visits received by the subjects ranged from 2
to 191.

In Analyses 9 and 10 the number of visits was entered into
the regression analyses as the treatment variable to analyze the
relationship of this variable to survivorship. A parallel analysis
with the length of survival as the outcome was felt not to be mean-
ingful because patients living longer would naturally have more
visits than those living shorter amounts of time simply because
they were around to have such visits. Analyses with length of sur-
vival were therefore not completed.

It was felt that the time during which the home care visits
took place could be an important influence on their effectiveness.
In particular, it was felt that the number of visits received by
the patients in their first month in the study, at a time presumably

closer to the health event that made them eligible for the study,

79

would be more important than visits occurring later in the study.

In preliminary analyses, therefore, the service intensity variable
was operationalized as two measures: the number of visits in the
first month and the total number of visits in months 2 through 12.
When these variables were entered into the regression analysis in
that order, the number of visits in the first month did not enter
significantly into the equation, while the number of visits in months
2 to 12 did. These variables were therefore combined and the total
number of visits was used as the service intensity variable in the
main analyses reported here.

In analysis 9 there was a significant relationship between
the total number of visits and survivorship (point biserial) correla-
tion coefficient = -.l9, p_= .006). The direction of this coeffi-
cient indicates that the more visits a person received the greater
the likelihood that the person would be alive at the end of the study.
10. Service Intensity with
Survivorship with Covariates

In this analysis the relationship between the number of
visits received and survivorship was analyzed while attempting to
control for any differences between subjects in the 13 intake status
variables. When these variables were entered first into a regression
analysis, the zero order correlation between the number of visits
and survivorship was reduced from -.19 to a partial r of -.13 and
the variable did not enter significantly into the equation (F to

enter = 2.46, p = .119). Thus, it appears that the relationship

80

between the number of visits and survivorship is largely accounted

for by the relationship of the intake variables and survivorship.

Interactions

The final set of analyses explored the question of interaction
between the subject intake characteristics and home care services in
their relationship with survivorship. The results of the regression
analyses reported earlier did not offer much support for the existence
of such interaction, but it was felt that an exploratory analysis
would be warranted by the findings of such relationships in several
of the twelve studies reviewed in the Introduction. The intake char-
acteristics chosen for analysis here, all of which had been included
in the 13 intake status variables used in earlier analyses, were
those that had been found to have such interactions in the reviewed
studies. These characteristics were age, ethnic group, living arrange-
ments, and the level of independence in the activities of daily
living.

In this study, regression analyses were done in which the
13 intake status variables were entered into the analysis first,
followed by the treatment variable, which was followed by the product
of the treatment variable and one of the four intake variables
selected (Cohen, 1980). This analysis was therefore conducted four
times with the experimental distinction variable as the treatment
variable, once each for age x treatment, ethnic group x treatment,
living arrangements x treatment, and activities of daily living x

treatment. In no case did this interaction term enter significantly

81

into the equation. For age x treatment, the E to enter was .001,
n.s.; for ethnic group x treatment, the E to enter was .04, n.s.;
for living arrangement x treatment, the §_to enter was .79, n.s.;
and for activities of daily living, the E to enter was 1.17, n.s.

These four analyses were repeated with the quasi-experimental
classification as the treatment variable, with similar results. In
this case, for age x treatment, the f to enter was .10, n.s.; for
ethnic group x treatment, the E to enter was 1.13, n.s.; for living
arrangements x treatment, the E to enter was .24, n.s.; and for
activities of daily living x treatment, the E to enter was .005,
n.s.

It would thus appear that any relationship between group
membership and survivorship in this study is not mediated by any of

the variables found to fulfill such a function in other studies.

CHAPTER IV
DISCUSSION

The present study is seen as one contribution to the crucial
task of investigating the patient outcomes that are associated with
home health care services, one of the currently proposed alternatives
to the present long-term health care system for the chronically-ill
elderly. This study was designed to examine the relationship
between one type of home care, that offered by a health assistant
as a part of a multi-disciplinary team of health care providers, and
one patient outcome, survival. There has been a great deal of recent
interest in home care because of its potential for better meeting
the needs of the chronically-ill elderly and doing so at a lower
cost than the currently institutionally-based long-term care system
(Blum and Minkler, 1980; Brickner et al., 1976; Colt et al., 1977;
Comptroller General of the United States, 1977; Somers and Moore,
1976; Van Dyke and Brown, 1972). Many observers have agreed, how-
ever, that rigorously designed evaluations of home care and related
community-based care programs have demonstrated few significant
effects on patient outcomes and have not resulted in any conclusive
consistent accounting of the outcomes that may be expected from
these programs (Doherty et al., 1978; Dunlop, 1980; Iglehart, 1978;
Kane and Kane, 1978, 1980; Urban Institute, 1978).

82

83

One exception to the general lack of significant findings
has been the ultimate outcome of patient survival. Community-based
programs have never cited higher rates of patient survival as a
realistic service goal for this chronically-ill elderly population.
In fact, few programs have even felt improved physical function to
be an achievable goal, and have focused on a slower rate of deterio-
ration in physical function, avoidance or postponement of institu-
tionalization, and improved patient and/or family morale. In the
Introduction, 14 experimental or quasi-experimental studies of
community-based care services that had included measures of patient
survival were reviewed. Six of the studies found that the experi-
mental group had a significantly lower mortality rate than the
control group (Bryant et al., Selmonoff et al., Skellie et al., and
all three studies of Weissert et al.). One study found that the
experimental group had a significantly higher mortality rate than
the control group (Blenkner et al.). Seven studies found no differ-
ences between the groups (Applebaum et al., Bakst and Marra, Hughes
et al., Katz et al., Nielsen et al., Posman et al., Weiss). The
fact that, contrary to expectations, half of the studies reviewed
found significant differences in mortality rates served as a major
impetus behind the present study.

In the present study, a multi-stage multivariate analysis
strategy, as advocated by Boruch and colleagues (1977, 1978), was
developed and applied to data on patient survival from a major

experimental study of home care (Papsidero et al., 1978). The

84

results from this intensive analysis of the relationship of service
use and survival can now be summarized.

The analysis strategy developed for this study included both
experimental and quasi—experimental approaches and different opera-
tionalizations of the use of home care services and survival. In
the experimental analyses, the comparison of the total experimental
and control groups revealed no differences in the number of patient5~
who were alive at the end of the study period. That any relation-
ship between group membership and survival was not suppressed by
differences between the groups in their status at intake to the
study was supported by the failure of the treatment variable to
enter the equation significantly after the entry of 13 measures of
the patients' intake status.

There was a marginally significant relationship between
experimental group membership and length of survival, the number of
days survived by those patients who did die during the study. How-
ever, the failure of the treatment variable to enter into the equa—
tion significantly after the entry of the intake status variables
indicated that any relationship between treatment and length of
survival was a spurious one accounted for by differences in patients'
intake status.

A series of quasi-experimental analyses comparing the experi-
mental group patients who actually used the home care services with
a group of user-like control group members was designed to permit
a more precise estimate of the relationship between service use and

survival in face of the fact that 60% of the experimental group

85

subjects received no--or only one--home care visit. The findings
from these analyses were very similar to those from the experimental
analyses described above, and offered no support for a relationship
between service use and survivorship or length of survival.

Another series of analyses also failed to support such rela-
tionships. The Blenkner et al., Skellie et al., and Weissert et al.
studies reviewed in the Introduction found that four intake status
variables: age, race, living arrangements, and independence in the
activities of daily living, mediated the relationship between ser-
vice use and survival. For example, patients living with others were
more likely to survive in the service group than in the control group,
while such differences were not found for patients living alone. In
the present study, the interactions of measures of each of these four
variables and the treatment group did not enter significantly into
the regression equations following the intake status and treatment
measures alone. These analyses thus offered no support for the con-
tention that any relationship between group membership and survival
was mediated by any of the variables found to fulfill such a function
in the studies reviewed.

Finally, an assessment was made of the relationship between
survivorship and a basic process measure, the total number of home
care visits received by those subjects receiving visits. Such a
relationship was found (point biserial correlation coefficient =
-.19 p_= .006) and indicated that those subjects receiving a greater
number of visits were more likely to survive than those receiving

fewer visits. However, this relationship appeared to be largely

 

86

accounted for by the relationship of the intake status measures to
survivorship, as the service variable did not enter significantly
into the equation following the entry of the status variables.

The results of this study indicate no support of any kind
for any relationship between the type of home care studied and sur-
vival. These results put this study firmly in the group of seven .
studies reviewed in the Introduction in which no relationship between
service and survival was found. There are several possible explana-
tions of why this study would be in this group rather than in the
other group of seven studies in which such relationships were found.

The first set of explanations concerns the possibility that
the type of home care service studied here does positively affect
survival rates but that this particular study failed to show those
effects. One possible explanation is that factors in the implemen-
tation of the research study, other than the treatment itself, were
responsible for the outcome. Such factors include the patient
samples, designs, measures, data collection procedures, follow-up
time periods, and so forth. For example, it could be that the ser-
vices assessed could affect survival rates, but the patient sample
did not include those who could show the greatest survival benefits.
Some support for this type of explanation can be achieved from a
comparison of the available data describing the Papsidero et al.
sample with that describing the samples from the studies with posi-
tive findings reviewed in the Introduction. To take one example,
patients in the Papsidero et a1. sample, when compared to patients

in the Weissert et al. homemaker study, seem to have been younger,

87

more likely to be male, less likely to live alone, and less dependent
in the activities of daily living. As the subgroup analyses performed
in the Weissert et al. study indicated that age, living arrangements,
and activities of daily living all influenced the results found in
that study, such differences in samples could account for some part

of the differences in results.

As another example, it could be that if measures other than
those used here were selected as operationalizations of the variables
of interest, different results would be obtained. Different opera-
tionalizations of intake, process, and outcome variables could all
be important. For example, the patients' living arrangements might
be revealed as a significant influence on their response to treat-
ment if the measure included more detail on the persons lived with
and the extent of present and potential support provided by those
persons. A more detailed understanding of the process of care and
its relationship to the outcome might result from the use of infor-
mation on the content of the home visits received in addition to
their number. Finally, it could also be that different operationali-
zations of the outcome variable of survival could result in different
findings. Although two different measures of this variable were used
in this study, this complex variable can also be measured in other
ways such as differences between actual survival curves and the
survival curves expected for persons of similar age and sex in the
general population.

As a second possible explanation, this study could have failed

to demonstrate existing effects of the home care services on survival

88

because of problems in the implementation of the treatment itself.
Sechrest et a1. (1979) present support and guidelines for a

greater concentration on assessing the strength and integrity of the
treatment in evaluation research. Boruch and Gomez (1977) have dis-
cussed the same concerns, describing the great decrease in statisti-
cal power resulting from a decline in treatment integrity. In their
reanalysis of the data from their study of home care reviewed in the
Introduction, Hughes, Cordray, and Spiker (1978) reiterate the impor-
tance of the inclusion in outcome analyses of data on the actual
implementation of the treatment, in their case, the number of home
visits received by the subjects.

In the present study, an examination of data on the number
of home care visits actually received by the subjects indicated that
only 40% of those assigned to the experimental group received more
than one home care visit. This level of treatment integrity certainly
severely reduces the possibility of any existing treatment effect
being demonstrated.

The efforts in this study to compare the service-users with
a more comparable group of user-like control group patients was
successful in that the discriminant function correctly classified
77% of the experimental group as service users or non-users and did
results in a large enough group of user-like control group patients
for comparison purposes. Of course, it is probable that the use of
this technique succeeded in forming a group that, while certainly
more comparable than the total control group, had been equated with

the service users on only a portion of the many factors responsible

89

for or related to their self-selection. The self-selection problem
remains a possible rationale for differences in outcome between
this and other studies.

As a further issue in treatment integrity, it can be noted
that the number of visits received by those patients that did receive
visits ranged from 2 to 191. In this study, the treatment was not
designed as a standard package such that each patient was supposed
to receive a certain number of visits no matter what his or her
condition. In common with other health care services, the number of
visits was determined during the treatment process as part of the
ongoing care plan individually prescribed for each person by the
team members. The treatment procedures as specified in Papsidero
et al. including in depth training of the team members, detailed
treatment guides, supervision by central office service providers,
and the use of the three-month baseline period in each site to test
treatment procedures before data collection began would indicate
some support for a contention that, for those receiving any visits
at least, appropriate levels of service were prescribed.

The number of visits was, of course, also influenced by the
length of time the patient remained in the study as determined by
factors such as the time at which he or she entered the study and
his/her institutionalization or death. Here again, the self-selection
factor was operating as the patients could accept or reject home care
visits at any time during the study. The wide range in the number of
visits received could, in summary, be seen as reducing the possibility

of locating any existing treatment effect. The use of the number of

90

vistis received as the operationalization of the treatment variable
in one set of analyses was seen as one possible approach to better
understanding any treatment effect, though in this case it did not
result in any different results from those in the other analyses.
The major alternative explanation for the results of the
present study is that the study resulted in a valid assessment of
this type of home care service and that there is no association
between this treatment and survival. It must be remembered that
community-based services were never designed or expected to have
effects on this ultimate health outcome and that the unforseen nature
of the significant findings in the studies reviewed in the Introduc-
tion was in part the impetus for this study. While the type of ser-
vice studied here seemed to be most similar to the studies of home
health aide care, the type that seemed most likely to be associated
with positive effects on survival in the literature, this explanation
would hold that the differences in outcomes could be due to differ-
ences in the services not accounted for in the rudimentary classifi-
cation system used in the Introduction. The type of service studied
here was newly developed especially for the Papsidero et a1. study
and no doubt differed in design and implementation in myriad subtle
and not so subtle ways from the home health aide services in the
reviewed studies in personnel selection, training, assigned roles,
rules of operation, etc. Even a seemingly minor difference in any
of these factors could conceivably be enough to account for differ-

ences in patient outcomes.

91

Directions for Future Research

As reported in the Introduction, a recent policy paper by
the Health Care Financing Administration (1981) concluded from three
of the studies reviewed here that "community-based services appear
to have a positive impact on survival rates" (p. 46). The overall
results of the 14 studies reviewed in the Introduction, as well as
the results of the present study, would seem to indicate the need
for major qualifications of that statement. If such over-simplified
interpretations of the literature lead to policies advocating any
and all types of community-based services for any and all elderly
patients, there may be unexpected and unfortunate results. The
critical need at present is for research to help clarify which types
of community-based services have what effects for what types of
elderly persons in which.settings. The results of such research can
then be formulated into statements of the type of care which is
likely to prove most beneficial for each type of patient. Only when
the criteria governing people's access to federally-funded community-
based care are grounded on such statements of expected benefits will
the long-term care system improve in effectiveness and humanity.

The first direction suggested for future research is the
analysis of the relationship of community-based services and survival
in other existing data sets. The application of the multi-stage
analysis strategy developed in the present study is suggested, with
multiple operationalizations of the use of services and survival,
with the use of measures of the patients' intake status as covariates,

and especially with the use of discriminant function in the formation

92

of groups of more comparable subjects as one approach to the common
problem of service self-selection. This research can contribute to
the field through further study of the effects of using various
operationalizations of intake, process, and outcome variables, and
of the comparability of groups established through the use of the
discriminant function technique.

An intensive analysis of survival data from multiple existing
data sets--data which in many cases have been subject to only cursory
analysis--could help to achieve a great deal of information about
the relationship between service and survival with a fraction of the
time and cost needed to mount a new study of the same topic.

The data archive in the Department of Community Health
Science, Michigan State University, contains or will very shortly
contain data sets and documentation designed for just such analyses
from five studies of comnunity-based care alternatives (Cumnings,
Kerner, Arones, and Steinbeck, 1980; Katz et al., Shealy, 1979;
Skellie et al., and Weissert et al.).

Finally, it should be noted that this study was not intended
to be an all-encompassing assessment of all possible outcomes of
service, but an intensive examination of one important outcome,
patient survival. A second direction for future research would be
to apply the analysis strategies used here to other patient outcomes
in the Papsidero et al. and other existing data sets. Other major
goals of a health care service for this chronically-ill elderly popu-
lation focus on quality of life. The aim is to maintain the person

at the highest level possible in physical, psychological, and social

93

function for as long as possible. In fact, although for simplicity's
sake in the present study survival was referred to as an exclusively
beneficial outcome, a service that kept patients alive for a longer
period of time, but at a completely dependent functional level, may
not be considered successful. Similarly, a service that did not
increase the number of days survived, but did increase the subjects'
level of function during those days, may be considered successful.
Any policy analysis evaluating the effectiveness of community-based
care should be based on an exhaustive synthesis of research on all
possible outcomes of care. Only in this way can the most accurate
picture of the complex synergistic effects of any service designed

to change people's lives he obtained.

APPENDICES

APPENDIX A
DESCRIPTION OF VARIABLES

 

94

 

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up . Ao—oomlcocv moo.uo:—oeoo gonna u m
Np. ugoooom
Azuoo co ouo>pco co o—pooov xocomo
:o .oeoz ::o «o: moot .oomopoeo uoz n c

 

mum . ucoooom “soon so oao>—co co u_~ooov
zucooo :o 05oz mczo .oozo—oso no: so
usoooom nouo>_co Lo o——o:ov oooooo go
«o: .oozo—oso uo: .osoz czo uo: moon u m
mom . Aoao>ogo so oopooov acooooo mooomo co «coooom zooomo ouo>oco
ao: .0Eoz :zo uo: moon .ooao—oso so acoooom zocomo oo—ooo
Aoao>pco so oopooov ugoooom oooomo mououo «cosxo—oEu
go no: .ooxo—oso uo: .oEoz mesa u N opzocoozo.oeoz
om .Asv—m F“ . Aoao>oco so o_pooov ugooooo zooomo Azouuv xocoocoooo
.Amvpm .m— H go go: too 03oz moxo .oozopoau u p . uosocoou mo xoo:_
v . ouoo oz
moo . twosome uoz u ~
N m cue . ooocgoz n — Ann—zz<zv monoum .ou_coz
a . ouoo oz
_ o me. u ouoomcop Lozuc u.n
o o So - 323 n N
. o _ om - zoo_m n _
om om _ cz<zo zo<om
oo—oo—eo> assoc Aoz<oo.zu<zmv ooocu ooczom
o . ouoo oz
. pom . z n N
woo - a u _ Axomo xom
c . mono oz
zoom m:_=oocom amino omooz Amw<v oo<
uuzozzoozmo
muzaom <h<a >uzm=ommm mo moz<z oz< wznoawl mmm=m<uz

mocomooz mo copuoocumoo
< x.o=0oo<.

95

 

o - o

o - o N_ - N
N - o No - _

NP .o. N N - o .oN - o zoNoov oo_: mo>_o meoooo No zoosoz
N - o o - N
N - o o. - N

P_ .o. _ o - o Noo - o zzmooao oo.z mo>oo moooNLN No Laoooz
N - o NN - N

N. .o. _ o - N Noo - o zoooo. go_z mo>.o moo.oo_ao Loooo No cooaoz
o - N

on - _ A

N. .o. _ moo - o zoom. oo_z mo>No ooo.—on oo zoosoz
N - o N. - N
o - o No - N

FN .op o o. - o moo - o Aoooxov oo.z ou>No oozo._oooooao co Loose:
N - N
No - N

N. .o. _ coo - o Nzomoo =N.: mo>oo oooo coo—o co zoosoz
_ - o N. - N
o - o oN - _

N. .oN _ o - o ooN - o AzoNNV oo.; mo>_o meow LoooooN No Loosoz
_ - N
NN - _

__ .o. _ moo - o No<ooo 53.: mo>No ocooooooo Loo—o No zooooz
N - o o. - N

N - o oo - _ Mo<o>v oo.: oo>_o ozooooooo

N. .o. o o - N moo - o Azooooo to on. Looooo> No Loosoz
ooN - _

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ooN - N

__ .o. _ oNo - o zua_=o oNN: out; mm>_o

oo - oooo oo

o. - N no - o
:o oN_-N
oN - o ooo -..

o o No - o No. - o Noozoozo Noooo.ooooo oo Loosoz

oooooo <Noo Nozoooooa go oozoo ozo ozoooo oooom<oz.

 

96

m . oeoo oz
mse . woos No «zoo» op
om. mzoox o— ooze moo.

.mcoo» m eooop e<

cop . meow» m :oze mmop
.coo» _ emoop e<

coo» o ooze mood

zezoa o ooze mooz

o . 3o: ogoze mze>oz

N . oeoo oz
cmp . zozec
-N . osoz m.oooooo so zzc

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eooeao—oeo m.ozozm=z emoo zoz zoo: oomoz
o. ozoom o.zoeo3 ooxoo—z so oooeo>eo

o .om—zzozeo .mzoe so meow» op so;
oozooez zooz moz ozo 03oz oze mo ooemeoo
oo—ooooo we ozm we .zoeeooooo ozo coeeoo
-oouo ozo zoz :o oomoz we «soon o.zoeo3
oozooez o "05oz oze 0o ovemeoo ammo—new
we ozm he .zoeeouooo ozo zoeeoooooo czo
coz co oomoo m. «Loom m.zosoz ooogo>eo o
moo—eooooo ozo :o_eoooooo m.ozozmoz coz
co oomoz m. ocoom m.:oso3 ooezzoe o eoze
ops; oze mzemo oogoom coon moz opzoezo>
oz» .A_— mo ezm—oz o moeeev ozooo
msooz— mo cocoon o oopo RN mo ezoeoz

o mos—ev zoeeoooooo oo—o Ne mo ezeeoz o
moeeev zoeeooooo :o oomoz m— ocoom m—zh

3N
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go: .58 8:83.... .3 25

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oeouze zopommz
o: "oozoememmo oe—zoo «meezouom
Noeuom mmzoo— "meuem "opozozo
-zeez "co—ozoo mzuopom "emocoe:_
"cocoozooooze ozo .gozoo
.ooeemozo «sooze :. emozop oe emozmez

 

~m . oeoo oz 2oz» ooxzoz o—oom ooezoppo» moo—o
mmp . ocouo emozoe u m osooz. 0o oogoom eoozo—z mo ozeeoz
mmm . o Nopoom osouze mo ougoom
—m .mwlmm mom i n zo—eooouuo
.ewloN .lenN mm 1 ~ ooeeoooom
.NNlNo .ooipo .5 ~ e 1 «zoom emozo—z u — Amumv ooo< 0ze mo moeoem oesozoouloeoom
muzzcm (kc: >uzmzauzu so uwz<z oz< azuoou mm¢=m<mz

 

97

zo—oemzzo econozo
ooo .ooeuemzzo
m.ezoeeon ooo
mogoooz —ou_oo:

ooeoemzzo
m.eoo_eoo ozo
mozooog pooeooz

— moon _

m u

op .p— _

.moeozoeo ooo .mEmopooo:
.msoemzm zoozospoo ozo .m:o>zoz
pozezou .—ozoz .zopoooo>oeooou
mo monommeo o>eeozozomoo

«so momozmoeo zeezo>om zoez

mp - oeoo oz
oom - zo_=
moo - so;

.mEoemzm xzoeo—ougeu

oze 5o momoom—o ooo .moouzo
omoom ooo soeoAm m=o>zoo
oze mo momoomeo .msmo—oooz
moo momooaoeo zmez zmez

co - oeoo oz
.oe . memoomoeo zm—z 3oz

mpz u memozmoeo xm—s zuez

o. . oeoo oz
mmm . ecu—eoo zee: eo:
mom a ecmeeoo zeez

op - oeoo oz

m__ - Lozeo
mo— - o>eeopoz Lozeo
e_~ - o_.zu
can . «mooom
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— u o mac

n u m mam

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l—N

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Axm—z¢<_av xmez ueemozmoea
m=h<hm :hz<wz z<o~w>zm

2:: 8.:
oo>ew ogou .ooeooego mo oozooemoz

Awumv ecmpeom oe
go>ea osou eooeozezo yo oezmzoeeopoz

szczuv meooeezozou Azoo—o so o—o
moo» moo e_=o< m=_zzc=-=oz oo Logos:

 

moz=Cm <h<a

>uzmacuzm zc moz<z az< uz~aou

mmzam<mz

98

ov .me .nc
.oe .me .ee _

m .e .m Ego»
mzeomozum
omoem em—

NN ..N _

op . oeoo oz
mum

om—

so

mm

mm—

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am

e u oeoo oz
mm

mm

mp—

mm—

opw

pom

.ezmeeooze go no so zoo

oze mo emos so ooz o.
ezoom mzomz oze emoo
moezoo ozoo mo Loosoz
"ozoo zeepezom—o own

5 . oeoo oz we
cam u o— mp
om - m— N—
NN u N— NN
cm I pp @—
mm n c. Nu
mN u a cu
nu u m mow

OPNMQ’U’O

PNMG’ID‘D

OPNM¢mON

Loemoozh .ouzooeezou .moeeo—eoh
.moeooou .azemmozo .oz_zeom
"z—eooozoooooe oszowzoo ezoeeoo
moeee>eeuo ozezop—om mo.zuo§=z ozh
zoo<v a=_>_o »__oo eo
moeee>eeu< o. oozoozooooo_ eo xooon

ace—pogo

go .mmozueeem .zeoo eoeon
saeaom so zmooo

zeoozz mo mmozeoozm

azez—o: zee: opoz zoo oooz
aoemmozo zeez o—oz so» ooo: .
geezeoa gee: a.uz goo no»: .
Azuuzomv "oezoeezo o—zemmoo xem

zoom zooem oeze zgezu so; oo—omeeom
oesoeezu ooeooozom eou—mzzo mo oozeoz

PNMVID‘D

za_o¢¢:o zeeoeoooz

 

muzaom <p<a

>uzu=cuzm zc muz<z =z< azuocu

mmz=m<uz

599

o— . oeoo oz
ooe - o. emozm.=
omN . a
pm . m
on n N .
mp - o
o— u m
o— u c
Np . m .mzoeemuoo cue mo eoo mgozmzo
p - N eooczoo mo zoosoz .oomgoo
m u — ooo .ouo—o .msee oe zo—eoezoego
o¢-oo _ N - o emmzoo zomzv og.o==o_emo=c maeoem .oecm:
moN . m .m mo ozoum
as - oeoo oz ae— . N oezemmoo no eoo momzooooo
mm on MM— I m 3 I —. ..UQHCQHCOU: MO 508532
.om .pm .oN H om— . o op . o A>oo<zv o_oom ecoseooeoou

.moooeou .mo>eeo_oz
N . oeoo oz Lozeo .omooom ze—z mazeze oo oe

com - emozo_: . o »e__.zo - momma N emo— c. as.
woo - u N -=o_eu==e o_og oo _o>o_ emazo_:
KN .mN .em _ so - emazoo u _ zo<ooomo a=_=o.eu==o o_o¢ .oeuom

m=h<hm zhz<mz z<~uomczu>mm

.zvoem :. meooeeoo e emoo— eo
so» ooEoz moo: oz: moo—o—m
-zzo sou .oo—oemAzo zoosezo
oeo>_zo oozxmez mo ooeoemzzo
oopoueeooo o o>oz eoz o—o go
oeo ezoeeoo oze Lozemz:

:oeuemzzo meze ooz u — moeeoueooe mo—zoezo> NN
zo—uemzzo meze u>oz eo: oeo a o . Ann can u p ooov :o—oemzzm
o u . oeoo oz zooem oeze oozoooom no:
we. - oozeo u N ezoeeoo zuezz zoom moooom

ops - —oeeomoz pozozom oe=o<

II
P

Auozzomv oozoom azezoozum

 

muzzom <h<o >uzm=omzm mo mwz<¢ oz< uz—ocu mmz=m<uz

1(30

meoozm Ne_>_eu<

.mh.m.>v .me.m.> oo>.ouog oz: oooze Nov

ecoememm< ze.oo= - . magma
Noo - oozeo - N
P .a .. o_N - .oe_omoz - _

Lgmvzmucv at: 0>u£ new: I —

 

oo>.ooog me.m.> oeoz No zoosoz
mmooozg .zoze<mae

Amo<zg .V :o.>ooez. No oo.eoooz

.meco.eoo

woos Lo m oozo.>zoeo.
oz: moozoe>zmeo. so;
.oozo.>goeo. so.:u.ezoo
o o>oz eo: o.o so

o.o ezo.eoo oze oozemz:
mo.eoo.oo. mo.zo.go> o.

 

eomzm zo>ou .. zozoe>zoeo. m.ze o>oz eoz o.o . o .o.-. Nz.v zmzo.>zoeo.
. o o o N.. . omen—co: u m
o . o o No. - 3oz.oom u e
o o . o NN. - zezooo eo.eogw u m
o o o . no. - zezoou mmou u N
c o o In «no . mo.ooz ooozw u .
ooem.:oz :oz.mom eo.eozw mmou
eomzm zo>ou .. mo.zo.zo> N555: oe.m
mmmuozo Nosz
omN . oeoo oz Nm . a
n. a m. mm . m
oN - N. mm - N
om . o. NN . o
NN . m. NN . m
we - e. o u v
on u m. a u N
no u N. m u N
mm . .. . n . m.oom moo.zeoz .ozo.mmouozo
ON on o No - o. . - o Azu><¢o oug=o_oo =o>o¢
mozzom <.<: Nuzmzamzu zo moz<z oz< oz.oow muzzmcuz

101

moeoo...ezou
zeooo .mo.go=e.zo
.mogouoz zooem

moeou.N.egoo
zeooo .mo.zooe.zo
.mozoooz zooem

.zooem oez.
Ngeoo No oeoo moo.s zeooo No «eon

s zeooo ..eos
zooem oeo. Ngeoo 5oz. ozoo No zozasz

. . ezomogo eoo oeoo.m.ezoo zeooo
o - eoomozo oeoo.N.eomo zeooo

.mozv .o>.>o:m No zemomz

:33» t as. on
eo: so o>..o m. :omooo N.
.m>.>¢=mv o.zmzo>.>z:m

uzouhzc

 

muzzom <N<o

>uzm=omzm mo mwz<z oz< wz.oou

mm¢=m<mz

APPENDIX 3
DATA COLLECTION INSTRUMENTS

102

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o'I. MAII‘I'S HUS‘I'ITAL
ammmm
NURSE-EXTENT APPRAISAL
AND
CHRONIC DISEASE MODULE
SCREENING QUESTIONNAIRE
I‘Mhaummflmmd-Immmmflnah .
‘ “momma-w . win-7' «madam? YM—
" ‘ . 3 imNWMummmua—Mumm m “J
5 human? VOL-J. 30—
(u
g ‘ ohhmmmm-nmmm” coma
. ”Wflmhfiummumw
g : hmdubuh-qummwi Vat-lo—
, so , w ,
3 g g . ummmmmammummm
3 g g 5 z 8 “Mammalian-Influen-
" much-I v" m
khflom ‘ Ummmwmm .
o _ . . ' 7 . ‘ . ‘ I m
g“ ‘ . I ohamuummwmaw '
. ~ ~ ”mu-Imam “niobium-ad '
‘
... ' amhaumuuammmwm'
_‘ N whommmmmdm .
- hunt-rm”! L y. "I
' g ' ‘ ' . Bl to.)
g z > I“. Yon—ha...
_ s - . ' ‘ - IN IN
E r"- . ' . ‘WWMMCWWfl-MMM ' N 1"“
- ~ 2 a ’3‘ ~ “mm-.9 . «...-....
I ‘bhmflmoflfismmm' a“ h.) m
. munflmhumhm' hm
- mama-Mb hi. “balsam-Imam
“M M...
I.” 7““
N - - .- 7 ' twain. ’ n.s..
«Manamaummmdm
macadmmm _
n ‘ , . LWOM'J”
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. I ,‘ tunic-datum III
' “ WGWI “...-Ia
nmmmamm m
Sfldmammu "
”Cu-OM You-'49
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3 _ LWImno-zdemmmmnummm y” x:-
u . g ofluénpaSmhnme-ufiums;,m‘m Io! "4
g u $2.1; «I III“ din ”"54 “ANGIE-ctr, Y‘s-Pu __
a 3" u I F
2 I; g: E “Ma-NarazuNuMs-auswumanum
'3' 3 g g q. ; aroma 199::me v.._\“
< v.- . g:
2 g u 3 5 u uvuuhoorr. mmaaiflmmeu new mom (:3
none-133:? 5,,
want I.' we» z-rACooy ' Lens 0! 999-934
I

ItUl-évt‘uf wu-Iua‘Cav-

103

SAINT MARY'S HOSPITAL
GRAND RAPIDS. MICHIGAN

Second-Stage Scre_ening Questionnaire
n.s.u. Evaluation Field Unit

 

I

l

i

 

FDLLOHUP

IDSP.

 

roe“ (EVALUATION new um omce use ONLY

“(SEER EITHER QUESTION 1 03 ALL PARIS OF QUESTION 2 Ag]; QUE‘JI‘ION 3.7

 

 

U
D

l. Regardless of present residence. does this patient need skilled
nursing services .in an institutional settin (such as a nursing

 

 

 

33 home. extended care ac . re a tation hospital. mental
hospital)? Yes U
' If 'Yes' is checked at right. list nursing services needed. 1‘
3' 5
In E .
E a

 

 

2a“. Regardless of present residence. is this patient able to reside
in a residential settin (such as patient's own hone. relative
or Triena's Home. Hotel, or state licensed permit home)? Yes [:7
2h. iiho is the person who helps the patifiept most in the residential
setting? (Use your best ,‘ucfoement and any information you

 

 

 

 

0".
STAGE SCREENIIB [ l PROCESSING

 

- (first name) I ‘

 

(last name)

 

 

 

 

 

 

 

 

 

 

 

,L have from the patient or fun y to answer this question.)
3 l. a relative (specify relationship)
“- 2. a friend or neighbor of the patient
. g 3. an employee of the patient or patient‘s family
*1 4. a nurse or other health service worker '
a 2. g 5. some other type of person (specify)
2c. lihat is the name, address and phone number .of the person check-
ed in 2b.? (Be as specific as you can. with the information
available to you. Leave address and phone spaces blank, if
the address is the same as the address and phoqeL at left.)—
We htfligg . ' .
E - (last name) (first name)
0
_ é (Street I number, if different from patient's)
1. (City I phone, if different from patient's)
0 2d. If 'yes“ is checked for 2a.. lisfi the services needed by the °
'2 ‘ patient. regardless of who prov as e serv ces In the resi-
: dential setting. .
fl
0 A
g a?
K: B -
.3- 'How would you describe the address ’ " DATE
.c um . ._ - - -- - . cowmso_1_1_
1. This is an institutional setting ‘

2. This is a residential setting . BY:

 

 

 

 

 

104

 

 

 

 

I' .
P
\_‘ "I ' . .
Fons-1e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. n. . \, ° .. ._
' - “ - - . .‘ .
a . O ..- . ' ’
" o ' ‘ . " ' T-
2 so = mrmxmr . . . 7'.
£3 E. ff; 2: - nImIII. women ( '_ ~-'.-~.,-. =_
.133 '31 _-.0fl'ioeofI-leelth Services Eduationendkeseerch
"--f--->.."‘_‘“‘ ' g. 1:...i-". Collgggofliuman Medicine ' . '. .. ~ ..
_' mmsmemvensm .3- _ . ' ... "‘
, . . ._ $3.1. . . ‘ . . - .' . . r. t . o. . .'-:. on . 0.. -
a La " -_ ' " T ' I.
so: ‘ ° ' I
uu . I'-
o '. .
-,-.-..,, :.'--‘--.__. .... . -. . ., .-.
l '. " - -' - . mmrme or
a . . . . .IIITERVIEH
amass ’ ' - . I ‘ “55707“- e
we
mm. umv'
- .I , v

105

“...L" mz- a—m. ra- ...- -.r. 3;." ‘t "=‘&‘- ..fl.’ 2'1. .7. “shed-‘3‘..- ‘—4 ' A P

Best Present Information: Discharge Address . _

sneer. ' ° ME TO BE -
' oIscImnoeo I I

cm - - m PHONE
' Best Present Information: ‘Primag Care Giver Age Sex 'Room I

we (Poo) ‘ cm I
smear ‘ RELATIONSHIP
cm ' ‘ m - - none

 

Contest the followigg m to arrangg initial againtment

 

. - ...... .'. '-..-oou . - v‘- "

. /To Be Filled ln By Data Controller\1

..0' ‘o ‘ one-v.

..--- ‘ OthcsPresent Durigglnterview- 53'. 2- ..-

 

‘ Role

*’ I am! my ’ Interview-

 

  

  

 

 

Recordoflntervieu'Attants ', , .- '.
. II
k
'. HR
IIII
us.
.2 uk
'5.
333‘" ~
games-”x. - ME '- ‘ sex 'cma.

‘l—PRI-Fora I6

 

W/
.. a

. ..- o
.'.---.——--.- a. -'- -.oo .0.

r._.

.K‘

1065

l. ARE YOU LOOKING FORWARD TO GOING HOME?
l. Yess, °
2. No

2. HOW LONG HAVE YOU LIVED IN YOUR PRESENT HOME? Time-
1. I'm moving there when I leave the hospital -
2. Less than a month .
3. Less than a year

Oil 4. At least l year. less than 5 years
5. .At least 5 years, less than 10 years
6. 10 years or more
9. No codable answer given

 

3. HHAT KIND OF PLACE ARE YOU GOING TO WHEN YOU LEAVE THE HOSPITAL?
PEAITIYOUR OHN HOME. SOMEONE ELSE' S HOME. OR SOME OTHER KIND OF
CE
1. My own or spouse' s home
13/2 2. Someone else's home ~
' 3. .A permit home
4. A hotel or boarding house
5. First specific ECF in area (end interview. see below)
6. Second specific ECF in area (end interview. see below)
7. Some other rehabilitation hospital (end interview. see below)
8. A nursing home (end interview, see below) -
9. Any Setting (as a class) to which the interviewer cannot obtain .
' entrance (end interview, see below) ' H
(Only for those who answered with a 5. 6, 7. 8. or 9). I WANT TO THANK YOU FOR
YOUR HELP HITH THIS STUDY. THAT'S ALL THE INFORMATION HE' LL BE NEEDING. GOODBYE.

, 4. HHAT HILL YOUR ADDRESS BE "HEN YOU LEAVE THE HOSPITAL? (AllowIsufficient ‘
time for an unprompted response. before you mention the address supplied
on page 1. Verify the address which has been given to you).

D/3

 

 

5. HHO IS THE PERSON WHO HILL GIVE YOU THE MOST DIRECT HELP HITH PERSONAL -
CARE AND HOUSEHOLD TASKS HHEN YOU HAVE LEFT THE HOSPITAL? (Probe: '
THINGS LIKE BATHING, DRESSING. LAUNDRY. COOKING, SHOPPING, CLEANING
AND SUCH?) WHAT IS THIS PERSON‘ S RELATION TO YOU?

PCGll a l. Spouse -
. 2. Other relative (specify)
3. Friend
5. Employee ,
6. Other (specify)

. (Ask only if the above named person does not live with participant)
NHAT IS THIS PERSON' 5 NAME. ADDRESS AND TELEPHONE NUMBER? (If ques-
tioned add. PART OF THE RESEARCH INVOLVES INTERVIENING THIS PERSON
YOU' VE MENTIONED ALSO.) 'Age_° Sex

Pcc/z - ° - - I ‘ telephone

 

 

 

 

(verify PCG address given on page T) .

107

 

 

 

 

 

 

 

1' t this 0131;;st items l-8 on the sensory functioning forms. However,
*1 the part cipant 1ves 1ndica1zion that a shorter 1nterview.: needed.
do all sensory function questions and proceed with item 7 be ow)_

. 7. ARE YOU MARRIED. DIVORCED. HIDONED, SEPARATED (intentionally), OR
._ HAVE YOU NEVER MARRIED? (note: Married takes precedence over also
' being divorced or widowed)
SEN/l I. Married (spouse may be separated for other reasons. such as
hospitalization. military service. etc.)
2. Divorced or separated (intentionally)
3. Hidowed

4. Never’married ‘ ‘ ' ' . >- ";

 

 

 

 

 

Ba. IS THERE ANY LANGUAGE OTHER THAN ENGLISH HHICH you SPEAK (CAN SPEAK;
EASILY) HITH FRIENDS AND/OR RELATIVES?
,Dl4a 1. No - speaks English onl
. 2. Yes (specify language(s )

 

8b. (Interviewer - observe, do not ask unless undecided) DO YOU THINK.OF
YOURSELF AS A BLACK (NEGRO) PERSON OR A WHITE PERSON?

D/4b 1. Black (Negro) person , . _ . _ . .
s 2. Hhite person _ . f g: ..
9. HOH MANY OTHER PEOPLE HILL LIVE HITH YOU HHEN YOU 9

LEAVE THE HOSPITAL?

1o. HHOHILL LIVE um YOU man You LEAVE THE HOSPITAL‘L (Table relationship
8: sex below)

11. mummmm (Tableagebelow) -~ _- _ .-..
12. mo Is THE HEAD or THE HOUSE-OLD on FAMILY? (am. mm; b01010

" _; ,13. BEFORE YOU HERE HOSPITALIZED. mo IN YOUR HWSEPDLD HORKED FOR MONEY?
(Place x in 'employed' space below) .
-—13a. ARE YOU EMPLOYED FOR MONEY OR PROFIT FROM YOUR HORK (even one hour
amonth)? (Record answer in row 7 below) -

14.. HHICH OF THESE PERSONS HORKS FULL TIME? (Place X in "full tflme' space below)
DIS,6,7.8. 9 l0 ’

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

("Relationship SFL. AGE Buployed Full Time.
‘ 1__ To Participant WP .
l. ' " "
£0
3.
- 4.
5.
5. \' . . . . . :
,- 7.‘ Self " ' ' " I-
' 3 - .8. Question skipped by RI _ .' r' . ,’ - _ ;;g;fl:v;flug
9. No codable answer given _ , - ‘ - 3 - » .;’"" '

108'

15. "HO OWNS THE PLACE "HERE YOU WILL LIVE?
ll. No one who lives there - residence is rented from others by
self or spouse
SEA/2 l2. No one who lives there - residence is rented from others by
. someone else who lives with participant
28. Self or spouse
31. Sun as line umber 1 page 4 (unless relative l is spouse)
32. Same as line number 2 page 4 . '
33. Same as line number 3 page 4
34.- Same as line number 4 page 4’ -
35. Same as line number 5 page 4
36. Same as line number 6 page 4 _
99. No codable'answer given “..-

16. DO YOU (OR YOUR SPOUSE) ON" ANY RESIDENCES OR PROPERTY OTHER THAN THE
.ELAEE.IOH.HILL.LI!£.1H7

3- l. At least 1 other residence I (we) have lived in previously
SEAAB 2. At least l residence I (we) have never lived in '°*"
, . 3. Other types of property -
4. No other property is owned by the participant (or spouse)
-5. no property is owned by the participant (or spouse)
9. No codable answer given

- o-o . no ' ...

zo. HAS YOUR HEALTH BEEN A How FOR You OllRIllG ll-IE PAsT Two vests? °
1. No - unqualified

CM/l 2. Any answer‘which indicates some worry
- . 9. Ho codable answer

 

21. HOW MANY DAYS HAVE YOU BEEN IN THIS PLACE (hospital)?
Mil

 

‘ (Number of days)
22. (Ask only inpatients who have been in the hospital less than l4 da

vs} .
How MANY DAYS am You STAY IN BED ALL OR MOST OF THE DAY, JUST P I
° "’2 BEING ADMITTED TO THIS PLACE (hospital)? R OR To

 

. (Number of days) ‘. -' .. '7'“

109

24. HOULO YOU SAY THAT DURING THE PAST THO WEEKS YOU HERE ABLE TO DO
MANY THINGS. A FEW THIHGS, OR NOTHING, HITH YOUR HUSBAND (HIT-E)?
(Table answer below)

25. HOULO YOU SAY THAT DURIHG THE PAST THO HEEKS Yw HERE ABLE 1'0 DO
HANY THINGS, A FEW THINGS, OR NOTHING, HITH YOUR OTHER RELATIVES?
(TaFFe answer below)

27. HOULD YOU SAY THAT DURING THE PAST THO HEEKS YOU HERE ABLE TO DO
.. MANY THINGS, A FEH THINGSLOR NOTHIPE. HITH YOUR fRIENDS?

283. mum YOU SAY THAT DURING THE PAST THO WEEKS Yul HERE ABLE TO WORK

FULL TIME PART TIME OR NOT AT ALL AT YOUR JOB? (EMPLOYMEHT FOR
PAY, ER HOUSE-15H, 3? flat is person' s occupation).
(Table answer below) ' ,

' SRIl,2.3.4 ‘ . (Mention of an contact,i .e.. phone call or visit should
be record 'a few things" )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

man a few ‘ . 100ESH'T APPLY Ho ‘
nothing
figs Hangs (not at all) I have no such Codable
(full time) (part time) re at on Answer
Spouse
Other Relatives
Friends
Hark (for pay)
Housework .-
OOH-PP! Form lo.- . ’

/\.

110

C

31. IN GENERAL. HOH SATISFIED ARE YOU HITH YOUR PLANS REGARDING YOUR.ARRANGE-
HENTS FOR HOUSECLEANING, COOKING. LAUNDRY AND SHOPPING. HHEN YOU GO HOME?

ARE YOU SATISFIED, PARTLY SATISFIED, OR DISSATISFIED? (Be sure to read

Chi/2 ,‘t'fie cfiol'ces to the respondentT

l. Satisfied (include 'I have to be satisfied')
2. Partly satisfied '
3. Dissatisfied - -
°‘ ,9. No codable answer given A . _
38. HHO COULD YOU TURN TO FOR HELP IN AN EMERGENCY? DO YOU HAVE SOHEBOOY'S NAME
' TELEPHONE NUMBER BY YOUR TELEPHONE (OR IN YOUR PURSE OR HALLET?) HHO
IS THAT PERSON? (Probe: IS THERE ANYONE ELSE? - IS THERE ANYONE IN
MICHIGAN?) (If more than one. record for “the one you'd call first“)

 

 

PCB 3 - ‘ ‘ '
' I Wane) (WtionT . .
(Street fiumber) (City) .' (PF—T—one . .

an.

‘-
\‘.

COH-PPI-Form 1.9,

V 111

44. ARE YOU MANAGING MOST OF YOUR PERSONAL CARE BY YOURSELF? LET'S THINK OF SOME
SPECIFIC THINGS. FOR INSTANCE. DOES ANYONE HELP YOU TO GET IN AND OUT OF THE
AOL/l BATHTUB OR SHO'iER? (In the past two weeks)
(Probe: HON DO YOU BATHE? IN A SHOliER? TUB? OR SPONGE BATH? DOES ANYONE
HELP YOU BATHE? If yes - DO YOU GET HELP HITH ONLY A SINGLE PART, OR NORE
ERA: ££¥£§7)DOES ANYONE GD HITH YOU TO YOUR BATH? DOES ANYONE BRING YOU YOUR

l. Indgggggent
a. a es self completely. in shower,  tub. or sponge bath.
b. ets assistance. support or supervision in bathing a single part
such as back or disabled extremity). or .
2. Dependent
a. gets assistance. support or supervision in bathing more than one
part of the body.w
b.. gets assistance, support or supervision getting in and out of the
tub. or to the bath »
c. has bath water brought to them
d. does not bathe self . .
,7. Refhsal .. I ~‘ . > ';« . f ‘ J‘_‘
9. No codable answer . < ' . ‘ ‘ '

45. HON DO YOU MANAGE YOUR DRESSING? (in past two weeks?)
(Probe: DOES ANYONE HELP YOU GET YOUR CLOTHING OUT OF CLOSETS AND DRANERS?
AOL/2 DOES ANYONE HELP YOU GET DRESSED? DO YOU GET DRESSED EVERY DAY?)

‘ l. Iodggggdent ”
. a. gets. clothes from closets and drawers and
' , b. puts on braces every day (if necessary)"and
, c. puts on clothes. outer garments, stockings and shoes or slippers,
, and manages all clothing fasteners (except tying shoes, or zi ping
,'- back zippers which is not necessary for an 'independent' code)
$922922
a. receives assistance or supervision in getting clothing out of
' closets and drawers or .
b. receives assistance or supervision in getting dressed or
c. does not change attire (i.e. remains partly undressed e.g. shoes
” off. in bathrobe over pajamas) _
7. Refusal , ‘
9. No codable answer .

.....mm. . - ' .- .. n

ll2

46. HON ABOUT TOILET ING? (in pasttwo weeks?)
(Probe: HOW DO YOU GET TO THE BATHROOM? DOES ANYONE HELP YOU HITH YOUR
TOILET ING - HELP-YOU HITH GETTING ON THE SEAT, HITH ARRANGING YOUR CLOTHING,
HITH CLEANING YOURSELF (PRIVATE PARTS). DO YOU EMPTY YOUR OHN BEDPAN (COMMODE)?

anus 1. Mat
' - a. gets to toilet room. a__nd
b. gets on and off toilet. a__nd
c. arranges clothes; cleans_ organs of excretion, or
d. may manage own bedpan or comode at ni ht onl and ties it
e. note: it is acceptable for P to use mechanical supports suEfi
as cane. crutches, walkers, wheelchairs. etc.

2. Dependent
a. uses bedpan or comoode during daytime. or uses either at night,

without gaping it. Lr
_b. rece ves ass stance or —supervision in getting to toilet room, or

c. receives assistance or supervision in getting on and off toilet
. seat or

d. receives assistance or supervision in arranging clothes. or

- cleaning organs of excretion . ,
7. Refusal
9. No codable answer

4]. CAN YOUSET IN AND OUT OF BED BY YOURSELF (AND/OR IN AND WT OF CHAIRS)? (in past
two wee

.(Probe: inHOOYOUGETOUTOFBED? HOHDOYOUGETOUTOFCHAIRS?) ....

AOL/4 l. Independent
. ' - . . - a. moves in and out of bed and chairs independently ~
' b. note: may or may not be using mechanical supports such as canes.
2 De crutches. walkers. wheelchairs. etc.
.' . went
a. assistance in moving in and out of beda ndl.[or chair or
' "b. does not move from bed or chair
7. Refusal
9. No codable answer

48. DO YW RECEIVE ANY HELP IN EATING? (in past two weeks)

AOL/5 l. Independent - ‘
a. gets food from plate (or its equivalent) into mouth
. . b- note:. not necessary that usual implements be used by P
c. note: acceptable to code as 1. independent if the participant
" receives assistance in preparation of food, such as precutting
of meat and buttering of bread. .
2.’ Dependent '
7 a. assistance given by other in act of feeding or
- . b. does not eat at all - reliant on intravenous feeding
~ 7.. Refusal , . _
.9. No codable answer ‘ ' - _ . ' . .-.__

.;_con-?Pl-Fornlo ' j:- ' ' “ ‘ ' H; 1.2.

113

49. DO CERTAIN FOODS SEEM TO GIVE YOU PROBLEMS HITH ELIMINATION? (in past two
weeks) DO YOU HAVE ACCIDENTS HITH DIARRHEA? DO YOU LOSE CONTROL OF
YOUR BOHELS OR BLADDER: DO YOU HAVE ACCIDENTS?

 

AOL/6 1. Independent
a. ur nation and defecation entirely self-controlled, either
by internal control or external management such as
enemas, suppositories colostomy, bedpan, urinal, etc.

2. Dependent
' a. partial or total incontinence in urination or defecation
or both _o_r_-
b. partial or total assistance or supervision of control by
enemas, catheters, or use of urinals and/or bedpans, or

- colostomy ~
7. Refusal

9. No codable answer -

SO. HOULD YOU SAY THAT YOU HAVE BEEN HAPPY OR UNHAPPY DURING THESE PAST THO HEEKS?

l. Hapw ' ' ‘ .
CM/3_‘ . _2. Both happy and unhappy , .'

3- Unhappy ‘

9. No codable answer given

51. LET ME new YOU A LIST or souncss or INCOME. mow mum or mass am You
(OR YOUR SPOUSE) RECEIVE YOUR INCOME IN THE LAST SIX MONTHS? (Circle
Well) '

SEA/4 (Ol)' ‘l. DURING THE LAST SIX MONTHS DID YOU (OR YOUR SPOUSE) RECEIVE ANY
. . ‘ INCOME FROM SALARY-‘ HAGES OR COMMISSION? (even if only l hours
work per moHEfiT'TETEE'BETEEEE'TEF'Efiy'Eroduct of the participant's
industry which results in a profit)
(OS)- 2. DURING THE LAST SIX MONTHS DID YOU (OR YOUR SPOUSE) RECEIVE ANY
- INCOME FROM SOCIAL SECURITY PAYMENTS? (toes not include 551 payments)
(09) 3. DURING THE LASI SIX MONiHS DID YOU (OR YOUR SPOUSE) RECEIVE ANY
INCOME FROM PUBLIC ASSISTANCE: (Aid to the Aged, Aid for the
Blind, Aid for the Disabled, Helfare payments of any kind including 55
(04) 4. DURING THE LAST SIX MONTHS DID YOU (OR YOUR SPOUSE) RECEIVE ANY
. ” 1 INCOME FROM PENSIONS 0R RETIREMENT FUNDS? (derived from own or
spouse‘ s past employment or savings, s"_h as: veterans' compensations,
‘ company pensions, retirement plans)
(02) 5.‘ DURING THE LAST SIX MONTHS DID YOU (OR YOUR SPOUSE) RECEIVE ANY
' INCOME FROM RAID UP ANNUITIES INSURANCE, INTEREST, DIVIDENDS, RENTALS,
,, ETC? (continuing income from a previous investment)
.(06) G. DURING THE LAST SIX MONTHS DID YOU (OR YOUR SPOUSE) RECEIVE ANY
' INCOME FROM HITHDRANALS FROM SAVINGS CASHING BONDS SELLING
THINGS YOU ORR? (one time income Tram a previous investment)
(07) 7. DURING THE LAST SIX MONTHS DID YOU (OR YOUR SPOUSE) RECEIVE ANY
"""" . A INCOME FROM GIFTS FROM CHILDREN, RELATIVES FRIENDS OR PRIVATE
SOCIAL AGENCI
(08) D. DURING THE LAST SIX MONTHS DID YOU (OR YOUR SPOUSE) RECEIVE ANY
. - INCOME FROM LOANS FROM ANY SOURCE?

9O 9. No codable answer . _ ‘ ~ ’ 'R .f'7h5.’I:—4—
70 TD. No income - . - ”

. _ . <‘
. , _. . _ V o _ ’ . . o . r
-~ - .7 :-
, o . . o o
e .0 ‘ e ,- T _ . . _ . _.
. . . . .a . ,- . .~ . e
. o ‘ - ' ' .' .
. e

CDM-PPI Fonm le _

H4

52. IN GENERAL HDH SATISFIED ARE YOU HITH YOUR HAY OF LIFE TODAY? ARE YOU
SATISFIED PARTLY SATISFIED, OR DISSATISFIED? (Be sure to read the
choices to participant)

l. Satisfied
CMI4 2. Partly satisfied
-——~\ - 3. Dissatisfied
- 9. No codable answer

 

53. HOULD YOU AGREE OR DISAGREE HITH THOSE PEOPLE HHO SAY, "THINGS JUST KEEP
GETTING HORSE FOR ME AS I GET OLDER”? ,
, 1. Agree ‘
CHIS 2. Disagree . ‘ g ,
‘ 9. No codable answer given ' ‘

59. HERE YOU EMPLOYED FOR MONEY OR PROFIT FROM YOUR HORK.JUST BEF R ENTER
THE HOSPITAL? (even l hour a month) . O E YOU ED

, 1. Yes
SEA/4 2., No - ' .
8. Question skipped by RI
SR/ll 9.

No codable answer

CDM-PPI-Form le I ‘ ' ' ‘ . - _ 14

“5

6T. HHAT KIND OF PAID NORK DID YOU DO AT THE HEIGHT OF YOUR WORKING CAREER? (This will
probably be the last type of work for both retired and still employed persons)
(this is not necessarily the work done for the longest time period. For instance,
a woman may have been a housewife for the longest time, but taught'school for

5 years. She was a teacher.or a housewife, depending on which Job she

feels was the height of her career.) -

SEN/2 ' '

ro e: NA.) N I

62. HAS THIS JOB HITH GOVERNMENT. PRIVATE BUSINESS. OR HERE YOU SELF-EMPLOYED?

' (government includes Federal, state, county, and local, as well as public
schools, and state universities, or military services) (do not assume farmers
are sel f-empl oyed) ‘

SEN/3 l. Government . .
~ 2. Business (private schools and non-profit corporations) - .
3. Sel f-.-empl oyed .
9. No codable answer

. 63. DID YOU HAVE A TITLE? HERE YOU ANY KIND OF OFFICER. OFFICIAL. OR PARTNER?
(especial ly important for managers, sel f-employed, military service, and
other governmental employees) (check for skilled, semi-skilled, and unskilled
or clerical, if person was ever a foreman or suoervisor)‘ (Probe: HERE YOU
INVOLVED IN ADMINISTRATION? HERE YOU INVOLV ISION? IS SO. HON
MANY PEOPLE DID YOU SUPERVISE ( HAVE UNDER YOU?) , _ '

szHii
(For Ersons epiplozed in government-skip 64, 652 and 66)
64. mm HAS THE NAME OF THE ORGANIZATION (COMPANY NAME)?
SW; . . _

(Asi: items 65 and 66 onlLfor persons: who were 'se'If-employed' in 62 or who were

f

LEW—MM; ‘n 63. Skip items 65 BM 6: TOW

.65. HHERE HAS IT LOCATED (cm AND STATE)? ' ' ' 3 '. '° '°
sat/5' - ‘ _ ' A

66. How LONG AGO HAS THIS'(HEIGHT OF HORKING CAREER)?

SEN/7 (years, approximately) ' ' . - .
67. WHAT HAS THE LAST GRADE m SCHOOL ’HchH YOU COMPLETED? (circle grade)

' SEN/8 l’. None K'Garten l 2 3 4 5 6 (Go to bottom of. page 16)

2. 7 8 9 (GO to bottan of page 16
3. 10 ll 60 to bottail of page l6

0

 

 

 

 

 

 

 

 

 

 

 

 

4. 12 (Ask #68)
9. No codable answer

CDl-l-PPI-Form le ls "

ll6

68. DID YOU GRADUATE FROM HIGH SCHOOL?
l

. yes .
SEN/9 2. no (skip 69,70,71, and 72)
8. question skipped by RI
9. Mo codable answer

69. DID {DU ATTEND COLLEGE?

. yes
SEH/lO 2. no (skip 70.71, and 72)
- ,8. question skipped by RI
3 ,9. No codable answer ,

70. HHAT HAS THE LAST YEAR OF COLLEGE (college credit granting institutiOn) YOU ‘

COMPLETED?
SEN/ll ;. I 2 3 (skip 71 and 72)

3.,5ormore
8. question skipped by RI
9. No codable answer

7l. DID YOU GRADUATE. HITH A BACHELOR'S DEGREE (OR EQUIVALENT) FROM COLLEGE?

l. {yes

SEN/l2 2. .no (skip 72) a
8. Question skipped by RI
9. No codable answer

72. DID YOU COMPLETE AN ADVANCED DEGREE (GRADUATE OR PROFESSIONAL DEGREE)?
l. No-not even a bechelor' s degree
SEN/l3 2. Nomcompleted a bachelor's degree
3. Yes-completed at least l graduate or profEssional degree
8. Question skipped by RI
9. No codable answer » -

(For all men and afll women who have never been married) go to page 20, skip
..mgs 7,13, 9 inkpaes - v

(For all women who have or°had husbands apk pages l7, l8, l9 (pink pages).

 

 

 

 

 

I

CDN-PPI-Form le _ ' _ A . ‘ _ ' l6 '

 

H7

- 73. HHAT KIND OF rAm woax om YOUR HUSBAND (EX-HUSBAND, LATE HUSBANDYDD AT

THE HEIGHT OF HIS WORKING CAREER? (This will probably be the last type
of work for both retired and still employed persons) (This is not neces-
sarily the work done for the longest time period. For instance, a man
may have been a carpenter for the longest time, but taught school for

5 ears. He was a teacher, or a carpenter, dependin on which job - -
h 5 wife feels was the height of his working career. 3

FSEH/l f 7 '
'-roe: D fl 'VBHA AHA HP "‘ H N» I . '0 til

74. HAS THIS JOB WITH GOVERhHJfl', PRIVATE BUSINESS, OR HAS HE SELF-EMPLOYED?
(government includes Federal, state. county, and local. as well as public

schools and state universities, or military services) (do not assume farmers
are self-employed)

1 . rsauz ;. Goverment

. . Business (private -schools A non-profit corporation) ° . ' . .n g ' ,

' '3. Self-emplo oyed . _ p _ . . . ‘ 7‘;

‘ 8. Question skipped byRI . - .- .- .' '
9. No. codable answer . - .' ; . ., .' _‘

' 75. DID HE HAVE A TITLE? HAS HE ANY KIND OF OFFICER, OFFICIAL OR PARTNER?

(especially important for managers, sel f-employed, military service. and
. other goverrm:ental employees) (check for skilled, semi -skilled and un-
:skilled or clerical, if person was ever a foreman or supervisor) (Probe:
HAS HE INVOLVED IN ADHINISTRATION? HAS HE INVOLVED IN SUPERVISION? IF
‘ SO, HON MANY PEOPLE DID HE SUPERVISE (HAVE UNDER Hm)? . .

Esau/3 - -- '. r - l " ° :’
(For persons employed in government skin 76, 77, and78 78) .

75. mm was THE um: OFTHE ORGANIZATION (comm NAME)? . _ ' _ 3 .
ism/4 ' x M—_ - -...

(Ask items 77 and 78 onl for persons: who were 'sellf-emolo ed“ in 74 or who were'
o?flcers or field titles ln businessi n 75. Skip items 77 and 7E Tor all l

others

 

 

 

 

 

77.- HHERE HAS n' Loom-:11 (cm on STATE)?
l-‘SEH/S * ' ° ’ ' -:

I 78. HO)! LONG AGO HAS THIS (HEIGHT OF l-la'ORKIiG CAREER)?

FSEH/G (years, approximately)

 

has. an. '- ‘0 17 .

118

79. HHAT HAS THE LAST GRADE IN SCHOOL NHICH YOUR HUSBAND CONRLETED? (circle grade)
1. None K'garten. l 2 3 4 5 6 (Go to top of page l9)
FSEH/7 2. 7 8 9 Go to top of page 19
, 2.” l0 ll Go to top of page 19
8. Question skipped by RI ‘ “ l
, 9.- No codable answer given .4

"80. DI? HE GRADUATE FROH HIGH SCHOOL?
. yes ‘
FSEH/8 2. no (Go to top of page 19)
8. Question skipped by RI < _
9. No codable answer given '; ~ ' . ‘ .‘ ‘

Bl. DID HE ATTEND COLLEGE?
I Yes

rsavs 2: No (Go to top of page 19)
8. Question skipped by RI
9. No codable answer given

82. HHAT’HAS :HE LAST YEAR OF COLLEGE} (college credit granting institution) HE-
FSEH/lO ;° 1.2 3 (Go to top of page 19)

3. 5 or more (ask 84) -
8. Question skipped by RI
> 9. No codable answer given

83. um HE GRADUATE. am: A man s DEGREE (on EQUIVALENT) Emu cmsez

1. (yes

FSEH/ll 2. no (Go to top of page l9)
8. Question skipped by RI
9. No codable answer given

'84. DID HE COMPLETE AN ADVANCED DEGREE (GRADUATE OR PROFESSIONAL DEGREE)?
1. No- not even a bachelor' s degree .
FSEH/lz 2. No - completed a bachelor' s degree '
- 3. Yes - completed a least 1 graduate or professional degree
8. QUestion skipped by RI .
9. No codable answer given

COM-PPI-Form le ‘ . . . ll l '- , I , . _ . I _ l8.~

out... ‘

119

(Ask the four remaining items only of women who are divorced or widowed
now and who have defined themselves as havingghad a work life. See Page 15.
1 1 others go to top of page 20;)

 

 

 

 

 

85. THE HORK YOU MENTIONED HHICH YOU DID YOURSELF - HAS IT DONE ONLY HHILE
YOU HERE STILL MARRIED. OR ONLY AFTER YOU HERE HIDOHED (DIVORCED OR
SERARATED)? .

FSEH/l3 l. Hbrk done only_while she was still married (Go to top of page 20)
2. Hbrk done 53th while married and when no longer married
3. Hork done afily_after end of marriage (skip to 87)
5. Hbrk done Bil before marriage (Go to top of page 20)
E. Hbrk done 56th 5e¥ore and after marriage. but not during
‘ marriage (skip to 87).
8. Question skipped by RI
9. No codable answer given

85. DID YOU KEEP RIGHT ON HORKING AFTER YOUR MARRIAGE. OR DID YOU START TO
HORK.AGAIN SOMETIME AFTER YOUR MARRIAGE?

 

FSEH/l4 l. Hbrked straight through between marriage and no-marciage (go to 88)
~ 2. Started to work again after marriage
8. Question skipped by RI
9. No codable answer given

1 87. HOH MANY YEARS AFTER THE END OF YOUR MARRIAGE DID YOU START TO HORK.(AGAIN)?

FSEHIlS ‘ 1. Less than one year
- 2. One year to less than five years
3. Five years to less than ten years
~ 4. TEn years or more
8. Question skipped by RI
9. -No codable answer given

88. HOH MANY YEARS HERE YOU HORKING AFTER YOU HERE NO LONGER MARRIED? (altogether)

FSEHIlG ~l. Less than one year
2. One year to less than five years
3. Five years to less than ten years ‘-
4. Ten years or more V
8. Question skipped by RI
9. No codable answer given

CDH-PPI-Form le ‘ ‘ ’ -' - " 19

./‘-\

120

CDH- PPI- Form le _ _ ' . , . __ .-- ---.--.___-_zp-._.

-'
11

(Ask items 89-98 before starting this page. Recgrd answers for this page'on
table. page Zl.) , _.-

NOH THIS IS A SO1‘lEl-1 'HAT DIFFERENT THING I' ll GOIl‘ 'G TO HAVE YOU DO

Ct-

(For participant who appears mentally alert, and physically able) I'H GOIT '6 TO .’
ASK YOU TO GO THROUGH THE PAGES OF THIS BOOKLET AND HARK THE CORRECT CHOICES

, ON THIS SHEET. (DON' T PAY ANY ATTENTION TO THE PAPER CLIPS) (You may help
participant by turning the pages.)

' (For participant who appears mentally alert but physically unable or unwilling
to write) I' H GOING TO ASK YOU TO GO THROUGH THE PAGES OF THIS BOOKLET AND »
TELL HE THE CORRECT CHOICE FOR EACH PAGE. (DON'T PAY ANY ATTENTION TO THE '
PAPER CLIPS) (You must have them tell you the number of the problem before
each answer choice. or you must visually verify that they are at the right
page of the book. They may turn two pages at once.-. .-If this happens early
in the test. all their answers will be in error. If they come out with one
acre or less answer than there are answer spaces, try again.) : j . . ”.3:

(For 1111 other participants) I 11 GOING TO ASK YOU TO LOOK AT EACH OF THE. .
PICTURES I SHOH YOU, AND DECIDE HHICH OF THE PIECES COHPLEYES THE PICTURE.
STANDARD DIRECTIONS FOR PICTURE A1 '1' ‘ ‘ t-i ”31...;
. o1nt nger at e ge 0 upper picture) THIS IS A PICTURE OF A ’3'
PATTERN(DESIGN)HITH A PIECE CUT OUT OF IT. EACH OF THESE PIECES (Point to. e.
- each of the six pieces in turn) IS THE RIGHT SHAPE TO FIT THE SPACE. (Use . '3"? ‘
- finger to go around the outline of figure 2., the plain green piece.- .Then - ° '
put your finger inside of the missing space in the upper figure) ONLY ON _ “
OF THESE PIECES IS THE RIGHT PATTERN (OESIG DTD HARE THE PICTURE 13W .' --
.POINT TO THE ONE PIECE HHICH IS RIGHT (TELL HE HHICH ONE PIECE IS RIGHT). . - ‘- 'f
TAKE AS MUCH TIHE TO DECIDE AS YOU NEED. BE CAREFUL, LOOK AT EACH PIECE. ...— (;
BEFORE YOU DECIDE. YOU HAY CHANGE. YOUR MIND IF YOU FEEL YOU NEED TO: , . .- ,. '. .-
(Tfter each choice is made, accept the choice with approval. such as an 11p ‘-. - --.‘ -
and down nod of the head. or OKAY] ALL RIGHT] FINE] GO ON] GO RIGHT AHEAD] '
3 GOOD] UH HUH‘I YES/ I'VE GOT THAT ANSHER, etc. Record the number of each ' --
answer in the recording space. If you think an answer is wrong, give no ’ " :-
hint of this to the participant. Keep moving right along. Do not ive a’
ositive res onse to a participant who fails to respond with a de 1111 Le "
. R’lEI‘iBER,O1‘lLY ONE I RIGH . -
HHICH ONE OF THE PIECES COHPLETES THE PICTURE? POINT TO THE ONE PIECE .
HHICH CANE OUT OF THIS PICTURE (PATTERN). TAKE AS MUCH TIHE AS YOU NEED,
BUT BE SURE TO CHOOSE JUST ONE OF THE PIECES.) _ - .

STANDARD DIRECTIONS FOR PICTURE Abl .
fiT—fi—f—WALL RIGH TO ARE As HUCH 11. As YOU NEED. BE SURE TO LOOK AT THE -
PICTURE OF THE PATTERN (DESIGN). ‘ HAKE CERTAIH you LOOK AT ALL 5111 PIECES --

  

* BEFORE YOU WAKE YOUR CHOICE.

STANDARD DIRECTIONS FOR PICTURE 31

REFEI—ET‘TU'T—ATTTPTCWRE'TOA 13 R L OK H SEE HHAT PART OF THE DESIGN IS l-lISSIHG. .
THEN LOOK AT EACH PIECE TO SEE 11HICH ONE CARE OUT OF THIS PICTURE. TAKE As
RICH TIRE AS YOU NEED. __ ,

HSQIT
USO/2

121

THAT NEARLY CO‘IPLETES THE INTERVIEW. THERE ARE JUST A FEW HDRE QUESTIONS
I MUST ASK YOU. _

89.
90.

1150/3
.' “SQ/4
1150/5
1150/5
’_ 1150/7 95.

“SQ/8 96.

1151119. 97.
(3 11511110 98.

HHAT IS THE DATE TODAY?

(Ask only if not given in answer to ”89" above) HHAT
HONTH IS IT NON?

HHAT YEAR IS IT 110111
HONOLDAREYOU?

HHATHONTHHEREYDUBORH?
1111ATTEAR11ERETDUDDRN2

HHAT IS THE NAT-IE OF THIS PLACE? (Probe: WHAT DO YOU CALL
THIS PLACE?) (Hrite out name of hospital.)

 

 

 

 

 

giHERE ES IT LOCATED? (Hrite out city. street or address
van. .

 

11110 IS PRESIDENT 01' THE UNITED STATES?
11110 HAS PRESIDENT BEFORE 111112

 

 

1:

3:1 :1 j  :1’1:1;3:1:1

(Record answers to. questions on page 20 in table below)

 

 

 

 

 

 

 

 

 

 

 

 

. 1
:LE - - 1e mi .- ~ --
115 ' O . In} L - . ..-.
'11 . A115 L":-1 -..--' ;' ...-
.lu 1g ' BL j.

319' 1:19 ' .115

{.111 Am . an

THANK YOU VERY MUCH FOR YOUR TIHE. '*
TO YOU AGAIN.

(If pgssibl , check over interview for completeness before leaving.)

6 .

CDH-PPI- Form le

 

I'LL BE BACK TD SEE YOU AND TALK
GOOD-BYE FOR 11011. ,

. ..‘V 21

122

HEALTH ASSIST ANTS Patient Nun.
ACTIVITY SHEET

1‘507 II "'1 lid '51.
11.1 ~11. com 1 fimfimd a... 11.133 win at]:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WWII“ melanin-(1'3!
01110111111111 {Eon-111g M

1mm 022mm 116111113me “m“ “m“m
zmuonoil’m (BMW 14mmnnuaanaan
imciFlniv awn“ 1 “lllfilll
ETW fire-Don Ewan mnallaollsawanaoua
:Rmmfiwfl “W... 1:513!!th [I I ' I
Cor-1mm 'omt Cone-'1‘ Earthw- Whit-cumin
LCD-.1 I . (11.13111 I M" '5 I 20. ojuauallal-nwunnsa
(nothpniemhomei 10.1mm 21.011111 J IUI --

_ pallulluuunauua
TnvdThl Tau Chm Tmmm Caged-ad Tm I 1]] ' l '
Doha-m Time Time Lithium mm MID-go MID-9o a a IIITDIITI 7: 7:1 71 10 7| 11 70
1.3121 22am 3317 31111 :13: was [__]|l 1: "

—

DP
Temp
Pub-
Wm
am
much 3...; ,. "‘ “ , ‘ "_h-wmw ”Item: My.“
Hunter ' “ them.lomsommym

 

 

 

 

 

REFERENCES

REFERENCES

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Bakst, H.J. and Marra, E.F. Experience with home care for cardiac
patients. American Journal of Public Health, 1955, ޤ, 444-
450.

Barney, J. The prerogative of choice in long-term care. Gerontolo-
Sjéi, 1977, 1_7, 309-314.

Blenkner, M., Bloom, M., Nielsen, M. and Weber, R. Protective ser-
vices for older persons. Final Report. Findings from the
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Available from the Benjamin Rose Institute, 636 Rose Build-
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Bloom, M. Measurement of the socio-economic status of the aged: New
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Bloom, M. and Blenkner, M. Assessing functioning of older persons
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Blum, S.R. and Minkler, M. Toward a continuum of caring alternatives:
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Boruch, R.F. Appropriateness and feasibility of randomized field
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Boruch, R.F. 0n making inferences in randomized experiments when
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Boruch, R.F. and Gomez, H. .Sensitivity, bias, and theory in impact
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Boruch, R.F. and Reis, J. The student, evaluative data, and secon-
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123

124

Boruch, R.F. and Rinskopf, D. On randomized experiments, approxima-
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CA: Sage, 1977.

Brickner, P.M., Janeski, J.F., Rich, 0., Duque, T., Starita, L.,
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25-29.

Bryant, F.B. and Nortman, P.M. Secondary analysis: The case for
data archives. American Psychologist, 1978, 381-387.

Bryant, N.H., Candland, L., and Loewenstein, R. Comparison of care
and cost outcomes for stroke patients with and without home
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Cohen, J. Partialed products 35g interactions; partialed powers are
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866.

Cohen, J. and Cohen, P. Applied multiple regression/correlation
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Lawrence EFlbaum Associates, Publishers, 1975.

Colt, A.M., Anderson, N., Scott, H.D., and Zimmerman, H. Home health
care is good economics. Nursing Outlook, October 1977, 632-
636 0

Commission on Professional and Hospital Activities. Hospital Adapta-
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Comptroller General of the United States. Report to the Congress.
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Educational evaluation: Analysis and responsibility.
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Cronbach, L.J. Coefficient alpha and the internal structure of tests.
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Cummings, V., Kerner, J.F., Arons, S., Steinbeck, C. An evaluation
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125

Deparment of Community Health Science, Chronic Disease Module
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Doherty, N., Segal, J., and Hicks, B. Alternatives to institutiona-
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Dunlop, 8.0. Expanded home-based care for the impaired elderly:
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1980, 7_0(5), 514-519. '

Gerson, L.W., and Hughes, 0.P. A comparative study of the economics
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§i4) 543-555. 1

 

Glass, G.V., McGaw, 8., Smith, M.L. Meta-analysis in social research.
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Health Care Financing Administration, Long-Term Care: Backgrougd and
future directions. Washington, D.C.: U.S. Government Print-
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Hedrick, 5., Katz, S., and Stroud, M.W. Patient assessment in long-
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vices Review, 1980/1981, 2(4), 1-19.

Hedrick, S., Papsidero, J., and Maynard, C. Analysis of alternative
definitions of function in studies of long-term care. Paper
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1981. Available from Department of Community Health Science,
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Hedrick, T., Boruch, R.F., and Ross, J. On ensuring the availability
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Hollingshead, A.B. Two-factor index of social position. Unpublished
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Hughes, S.L., Cordray, D. and Spiker, A. Preliminary findings from
the evaluation of a comprehensive home care program for
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Available from Center for Health Services and Policy Research,
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Hughes,

Hunter,

126

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