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Social Support, Home Health Service Use, and Outcomes Among Four Racial–Ethnic Groups

Correspondence: Address correspondence to Timothy R. Peng, PhD, Center for Home Care Policy and Research, Visiting Nurse Service of New York, 5 Penn Plaza, 11th Floor, New York, NY 10001. E-mail: tpeng{at}vnsny.org

	Abstract

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Purpose: This study explored similarities and differences in social support, home health service utilization, and health outcomes across four racial–ethnic groups of elders. Design and Methods: 1999 Outcomes Assessment Information Set records for 7,374 home care recipients who were 75 years of age or older and who were discharged to self-care were selected for bivariate and multivariate analyses. Results: Similar levels of skilled service utilization were observed across racial or ethnic groups. Disparities were found in supportive assistance and physical and mental health outcomes. At discharge to self-care, more Black elders had no supportive assistance compared with all other groups; fewer Hispanics and Asians had improved physical functioning compared with Black and White elders. More White elders reported anxiety and depressive symptoms than any other racial or ethnic group. Implications: The findings suggest that racial–ethnic minorities and White elders may have differential needs for mental health and supportive services at discharge from home health care.

Key Words: Home health care utilization • Race • Ethnicity • Disparities • Home- and community-based services

There has been limited research on the physical health outcomes of elders in home health care. Some studies of community-dwelling elders have suggested that social support can be a critical predictor of physical functioning after an episode of illness. However, the effect of social support on health outcomes may depend on the nature of the caregiver–care recipient relationship (Stoller & Pugliesi, 1991), because having more support has been linked to both improvement (Oxman & Hull, 1997) and decline (Mendes de Leon, Gold, Glass, Kaplan, & George, 2001; Penrod, Kane, Finch, & Kane, 1998). Research on psychological functioning has shown that fears of disability and low levels of social support are related to increased depression and stress (Chatters, 1993; Husaini et al., 1991; Krishnan et al., 1998).

Research on the health outcomes of older minorities has shown that beyond approximately 70 to 75 years of age, Black elders have better mortality outcomes compared with White elders of their cohort, a phenomenon described as the "crossover effect" (Gibson, 1994; Watson, 1990). Although such improved survival rates may indirectly suggest the presence of better physical health status (Chatters, 1993), direct measures of physical health suggest that Black elders 65 years of age and older have higher rates of disability (National Center for Health Statistics, 2001) and are actually sicker both in and out of the health care system (Coward et al., 1997; Netzer et al., 1997; Proctor et al., 1997). With regard to psychological outcomes among minorities outside of the home health setting, the literature suggests that increased social support is associated with lower rates of depression among Black elders (Husaini et al., 1990, 1991).

Past research on racial or ethnic minorities in home health care has primarily focused on preferences for long-term care settings and predictors of service utilization. Minority elders have been found to prefer home- and community-based care settings even more strongly than White elders (Chee & Kane, 1983; Damron-Rodriguez, Wallace, & Kington, 1994). This finding has been attributed to sociocultural differences in kinship relations or expectations of filial responsibility (Watson, 1990), socioeconomics, and other restrictions to access (Wallace, Levy-Storms, Kington, & Andersen, 1998). However, although racial–ethnic minority populations in general have been found to hold strong beliefs in children's responsibility to care for elderly parents, their utilization of formal home health services has not been shown to differ from Whites (Lee, Peek, & Coward, 1998; Lee & Peng, 2001). Thus, if beliefs about filial responsibility drive the choice to remain in the community setting among racial or ethnic minority elders, such beliefs do not appear to result in substitution of informal care for formal care (Netzer et al., 1997). Other researchers have suggested that the choice of long-term care settings is highly individual, without a strong relation to racial–ethnic group membership (Mitchell, Mathews, & Hack, 2000), and there is evidence that factors such as depression, chronic illness, and social isolation are reliable predictors for entry into home care (Cagney & Agree, 1999; Freedman, 1999).

A major limitation of past research has been the restriction of group comparisons to Black and White elders, often attributed to the difficulty in achieving sufficient sample sizes of Asians and Hispanics in readily available data (LaVeist, 1995). However, as Hispanic and Asian populations are projected to be among the most rapidly growing groups of elders (U.S. Bureau of the Census, 2000), their exclusion represents a substantial gap in the literature. Moreover, to date there has been little research on these populations in a home health care setting. Research on home care using Medicare claims is limited by the requirements of the Medicare benefit, which is directed at patients following an acute event, usually from a hospital setting. Another limitation of previous research has been the use of data drawn from the general healthy adult population, without specific attention paid to community-dwelling disabled elders who may have a high risk for needing formal health care services.

The purpose of the current study is to extend previous research by focusing on four different racial–ethnic populations of elders who have been discharged to the community after receiving home health care services. Three specific research questions are addressed: First, are there differences in social support structures at discharge to self-care? Second, what are the predictors of skilled home care utilization? Third, what are the predictors of physical and psychological health outcomes?

	Methods

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Study Sample
The sample was drawn from initial Outcomes Assessment Information Set (OASIS) records of patients who were served by a large Medicare–Medicaid certified home health agency in a Northeast urban area. Included were all patients 75 years of age or older who were admitted in 1999 and discharged by October 2000 (N = 20,826). Patients were included regardless of payer or referral source. Thus, the sample included those who may have been referred to care directly from the hospital (56% of the final sample) as well as those who may have been referred to care by a community physician (e.g., for symptom management and control). For patients admitted multiple times, only the first admission was included. Of this population, 25% (n = 5,213) were discharged because of hospitalization, 2% (n = 337) were discharged to other institutional settings (e.g., a nursing home or congregate living facilities), 10% (n = 2,104) were discharged to other formal community-based care (e.g., other home health care agency, hospice care, or home attendant service), 2% (n = 410) were deceased, and 9% (n = 1,854) were lost to follow-up or were discharged for miscellaneous reasons (e.g., refused care). The remaining 52% (10,908) were discharged to self-care or community care, of whom 69% (n = 7,478) had complete discharge OASIS assessments. For analytic purposes, the study sample was stratified into the following patient self-identified racial or ethnic groups: White, non-Hispanic (n = 5,086); Black (n = 1,305); Hispanic (n = 781); and Asian (n = 222). No provision was made for identification into multiple categories (e.g., Black and Hispanic); thus patients self-selected a single primary identification group. Omitted from the study were those who self-identified as American Indian, Native Hawaiian, and those for whom no race or ethnicity data were available, representing approximately 1% (n = 84) of the sample. The final study sample included a total of 7,394 home health recipients.

Measures
The OASIS assessment tool contains a variety of measures on the physical and psychological functioning of home health recipients (Shaughnessy, Schelenker, & Hittle, 1994). Admission and discharge OASIS records were linked to agency administrative data to extract the following information: sociodemographic characteristics (e.g., age, sex, race or ethnicity, and insurance status); social support structure (e.g., presence of an informal caregiver, presence of a primary caregiver, and type of informal care received); use of formal care other than home care; home health service utilization (e.g., number of skilled nursing, therapist, and social work visits); and dependence in physical functioning, including activities of daily living (ADLs, such as grooming, dressing, bathing, toileting transferring, ambulation, and feeding) and instrumental activities of daily living (IADLs, such as meal preparation, transportation, laundry, housekeeping, shopping, and telephone), which are defined as requiring human assistance to perform the respective activity. Scales of ADL and IADL dependency were constructed, following Spector and Fleischmann (1998), by summing the total number of ADL and IADL dependencies. Psychological functioning was assessed, for example, with the presence of anxiety categorized as 1 = anxiety present less often than daily, daily but not constantly, or all of the time, and 0 = no anxiety present. The presence of depressive symptomatology was measured dichotomously where 1 = depressed mood reported or observed and 0 = no depressed mood indicated. Cognitive functioning was categorized as 1 = requires assistance in specific situations, requires considerable assistance in routine situations, or is totally dependent such as constant disorientation, coma, persistent vegetative state, or delirium, and 0 = alert or oriented, or requires prompting only under stressful or unfamiliar conditions. Confusion was categorized as 1 = confused on awakening or at night only, during day and evening, or constantly, and 0 = never confused or confused in complex situations only. The number of comorbid conditions, the primary ICD-9 diagnosis (where ICD stands for International Classification of Diseases), and the severity of the primary diagnosis were also obtained.

Episodes of Care
The time frame for the cases used in the analysis (January 1999 through October 2000) occurred while Medicare home health care services were being reimbursed through the interim payment system (IPS), which was subsequently replaced by the Medicare home health prospective payment system (PPS). During IPS, OASIS assessments were conducted at admission to care, every 60 days from admission if the episode lasted beyond 60 days, and at discharge from home health care. However, an episode of care, from admission assessment to discharge assessment (as used in this study), was not defined by the regulations but remained under the determination of the skilled nurse who coordinated the patient's care. Thus, the episodes included in this study are defined by OASIS assessments taken at admission, in 1999, to OASIS assessments made at discharge from care (not including any 60-day assessments or transfer assessments).

Statistical Analysis
Descriptive statistics (e.g., means, standard deviations, and frequencies), bivariate comparisons (e.g., Mantel–Haenzel chi-square and Student's t tests), and multivariate models were conducted by using SAS software (SAS, Cary, NC). Ordinary least squares regression was used to model home health service utilization, which was computed as the sum total of all skilled visits (i.e., nursing, physical and occupational therapies, and social work) as a function of demographic characteristics (i.e., age, sex, and race–ethnicity), general health (i.e., comorbidities and pain at admission), insurance status (i.e., Medicare without Medicaid including Medicare with supplemental insurance, Medicaid only, or dually eligible for Medicare and Medicaid), presence of additional care (formal or informal), physical functioning (sum total of ADL and IADL dependencies requiring another person for assistance), and psychological functioning (depressive symptomatology and anxiety) at admission. A logarithmic transformation of the utilization variable was used to address skewness in the data distribution.

A series of logistic regression models was used to estimate the effect of factors on physical and psychological functioning at discharge. Physical functioning outcomes were examined by two models of improvement or stability from admission as compared with discharge. One model examined ADLs (0 = more ADL dependencies at discharge compared with admission, and 1 = fewer or the same number of ADL dependencies at discharge compared with baseline), and the other examined IADLs (0 = more IADL dependencies at discharge compared with admission, and 1 = fewer or the same number of IADL dependencies at discharge compared with admission), as a function of demographic characteristics, general health, insurance status, presence of additional care (formal or informal), and psychological functioning at admission, while controlling for baseline physical function. Psychological functioning was measured by using two dependent variables, presence of anxiety (0 = No, 1 = Yes) and depressive symptomatology (0 = No, 1 = Yes) at discharge, as a function of demographic characteristics, general health, insurance status, presence of additional care, and physical health functioning, while controlling for baseline levels of anxiety and depressive symptomatology. Crude (unadjusted) and adjusted odds ratios (ORs), 95% confidence intervals (CIs), and p values were calculated.

Case-Mix Adjustment
Although all patients in the study were served by a single agency and resided in a single geographic region, differences may arise in the sociodemographics as well as in the diagnosis-based case mix across each of the racial–ethnic categories used for comparison in this study. For example, diabetes and hypertension may be more prevalent among Black, Asian, and Hispanic elders than among White elders. Thus, all multivariate models included adjustments for patient case mix based on primary ICD-9 diagnoses. With the use of the most frequent diagnosis at admission to home care, congestive heart failure (CHF), as the comparison group, indicators of the following top 11 primary diagnoses were entered in the models: essential hypertension, diabetes mellitus, osteoarthrosis, coronary atherosclerosis, stroke, tachycardia, hip fracture, nervous or musculoskeletal symptoms, decubitus ulcer, pneumonia, and chronic obstructive pulmonary disease. These diagnoses, along with CHF, accounted for approximately half of all admissions. Remaining patients were grouped into the following disease-based categories: wounds, dermatological diseases, degenerative disorders, cardiovascular diseases, neurological disorders, cancer, infectious diseases, orthopedic diseases, enteropathy, metabolic diseases, arthropathy, and other. Finally, the severity of the primary diagnosis, as assessed by the nurse at admission by use of a 5-point scale (0 = asymptomatic, 1 = symptoms well controlled, 2 = symptoms controlled with difficulty, 3 = symptoms poorly controlled, and 4 = history of hospitalizations), was included as a within-diagnosis case-mix adjustment. Only the case mix based upon the primary diagnosis is included in the multivariate models; no case-mix adjustment was made on the basis of secondary diagnoses. However, as already noted, the total number of comorbid conditions is included as a covariate.

	Results

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Descriptive Analyses
Sociodemographic Characteristics of Home Health Recipients
Most home health recipients were 75 to 84 years of age, female, and Medicare recipients (Table 1). On average, White home health recipients were older than those in the other racial–ethnic categories and were significantly more likely to have Medicare (without Medicaid) for insurance coverage. Black, Hispanic, and Asian home health recipients were much more likely to be covered by Medicaid only or to be dually eligible for both Medicare and Medicaid as compared with White home health care recipients. Hispanic home health recipients had a particularly high rate of dual eligibility. Additionally, among Asian home health recipients, there was a significantly higher proportion of men.

Examination of psychological health outcomes revealed that approximately one third of all patients were reported to have anxiety or confusion present at discharge, approximately one fifth had signs of poor cognitive functioning, and nearly one fifth were reported to have depressive symptomatology. A smaller proportion of Black home health recipients had depressive symptomatology at discharge as compared with Whites or Hispanics, whereas a greater proportion of White home health recipients showed the presence of anxiety at discharge compared with the other groups. More Hispanic home health recipients had poor cognitive functioning at discharge compared with Blacks and Whites. Finally, Whites had significantly lower rates of confusion at discharge as compared with Black and Hispanic home health recipients.

Home Health Care Service Utilization
As shown in Table 3, on average, home health recipients received at least two different types of home health services. White and Asian home health recipients had a greater variety of services than Black or Hispanic home health recipients. This difference can be attributed to the higher proportion of Whites and Asians who received physical and occupational therapy. Black and Hispanic home health recipients were significantly less likely to have received multiple services compared with White and Asian home health recipients.

Psychological Functioning Outcomes
As shown in Table 6, the strongest predictor of anxiety or depressive symptomatology at discharge was the presence of anxiety or depression at baseline. After baseline psychological functioning was controlled for, home health recipients who were men, Black, or Hispanic were less likely to experience anxiety at discharge. In contrast, the likelihood of experiencing anxiety at discharge increased with greater IADL dependency. The findings also showed that Black, Hispanic, and Asian home health recipients were less likely to report depressive symptomatology at discharge as compared with White home health recipients. Goodness of fit for the anxiety and depressive symptomatology models was sufficient to reject the null hypothesis of poor fit for both (Hosmer–Lemeshow test ² = 9.73, p =.2843, adjusted R² =.19 for anxiety; Hosmer–Lemeshow test ² = 1.38, p =.9946, adjusted R² =.20 for depressive symptomatology).

	Discussion

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Among all of the racial or ethnic groups examined, however, Black elders were more likely to be alone with no form of supportive care, whether formal or informal, at discharge to self-care. Past research has shown that social isolation among Black elders, especially among women, is associated with increased risk of poor health and the need for long-term care (Cagney & Agree, 1999; Freedman, 1999; Husaini et al., 1990, 1991; Simonsick, Kasper & Phillips, 1998). This study's findings suggest that discharge planning and follow-up focusing on community or other available resources for assistance should be considered for the substantial number of frail elders who are discharged from formal care services to care for themselves with little or no supportive assistance.

Consistent with prior research (Lee et al., 1998; Netzer et al., 1997), this study found that the overall volume of home health service utilization did not differ across racial or ethnic groups. This finding suggests that although attitudes toward the use of formal care may be subject to cultural differences across diverse groups, the actual utilization of services by disabled elders may be driven by other factors such as clinical or disability-based needs. However, it is important to note that the study sample represents a population that has already entered the health care system, having already overcome potential access barriers to home health care services. Differences in the types of services used are typically driven by factors such as clinical severity or diagnosis. Thus, although the bivariate comparisons of service mix across racial or ethnic groups is interesting, further research is necessary to determine the underlying causes of these differences.

The finding that older home care recipients, men, and those with social support were more likely to have experienced a greater risk of decline in physical functioning at discharge on both ADL and IADL dependencies concurs with recent research. Disability has consistently been found to increase with age (National Center for Health Statistics, 2001). Gender differences among IADLs often are attributed to the fact that the measures may be sensitive to cultural bias in sex roles with respect to some of the activities described (e.g., cooking or cleaning), leading men to report greater dependencies. With respect to ADL functioning, women are typically found to report higher absolute levels of disability but also have lower rates of mortality as compared with men (National Center for Health Statistics, 2001). Our finding that men had a greater risk of decline in ADL dependency (as opposed to absolute level of dependency) is consistent with recent research on community-dwelling elders with heart failure (a highly prevalent diagnosis among patients receiving home health care), which found men to have higher morbidity over time as compared with women (Jong, Vowinckel, Liu, Gong, and Tu, 2002). The negative relationship between social support and physical functioning may be a result of a "learned dependence" of care recipients upon caregivers (Penrod et al., 1998), whereupon the presence of supportive care actually inhibits recovery from physical disability. It also is plausible that simply knowing that a patient receives human help with a functional task may influence formal caregivers (who perform the OASIS assessments used in the analyses) toward the perception that the patient has dependencies in performing that task.

Across the racial–ethnic groups, there were no differences found in the stability or improvement of ADL dependencies. However, when a variety of factors were controlled for, Hispanic and Asian home health recipients were more likely to experience decline in IADL dependencies. Further research on the physical health outcomes of frail Hispanic and Asian elders is needed to determine possible contributing factors to accelerated decline in the physical functioning of frail elders in these populations. The lack of strong fit in both models of physical functioning outcomes raises the possibility that these outcomes are largely determined by underlying disease trajectories that would not be affected by a limited episode of home health care. Even so, there continues to be a need for exploration of factors beyond traditional predictors for the modeling of physical functioning outcomes.

Across all patients, the single strongest predictor of poor psychological functioning at discharge was the presence of poor psychological functioning at admission. This suggests that individual or situational factors leading to psychological distress (as defined by the presence of anxiety and depressive symptomatology) are relatively stable. If so, it may be overly ambitious to expect a limited number of home health care visits aimed primarily to enhance physical functioning to have a significant effect on long-term psychological functioning. However, even after the baseline presence of poor psychological functioning was controlled for, among all racial or ethnic groups examined, White home health recipients had a significantly greater risk of poor psychological functioning outcomes. This is consistent with past research that has shown that medical disability is particularly stressful for White elders (Husaini et al., 1990), and that in urban settings White elders experience greater psychological distress than minority elders (Neff & Husaini, 1987). Nevertheless, medical disability is a source of stress for minority populations as well (Brown, Ahmed, Gary & Milburn, 1995; Chatters, 1993). One possible explanation for these findings is that psychological distress has not been as thoroughly studied and measured for older minorities as it has for general adult populations. Furthermore, the OASIS measures used here are not validated for minority populations; nor are the nurses who administer these measures required to be trained in conducting psychological assessments.

The findings of this study should be viewed in light of certain limitations. First, because the data were drawn from a single large urban home health agency, the study results may not be generalizable to home health care recipients in rural or suburban areas. For example, the analysis of skilled service utilization by a single agency may not reflect differences in the distribution of care provided by skilled professionals versus paraprofessionals (such as home health aides) across different agencies. Second, the study sample was derived from a single state, and thus regional differences in demographics and local variations in health services policy (such as Medicaid access) may not be reflected in the results. Third, this study examined a specific group of oldest-old home health recipients, namely those who were discharged to self-care or community care. Although a large body of research has documented the crossover effect among White and Black elders in the general population, it has been suggested that among frail elders who are already receiving institutional care, Blacks are more likely to remain in care or die while in care as compared with Whites (Greene & Ondrich, 1990). Although the focus on home health recipients returned to self-care in the community is an important criterion for the current study's objectives, it leaves the findings inapplicable to those care recipients who are discharged to hospitals or nursing homes, die, or are otherwise lost to follow-up, who represent a majority (65%) of those who entered home health care during the study period. Only those home care recipients who are discharged to self-care or community care are reliably seen by their nurse and thus have a consistently confirmed discharge outcome. Further research is needed to explore ways to identify and confirm the outcomes of home care patients who are not discharged to self-care or community care, and to determine the factors contributing to their respective discharge outcomes. Fourth, measures of anxiety and depressive symptomatology used in this study were not assessed by validated psychological health scales. Finally, although all racial or ethnic groups of elders received a similar volume of skilled home health care services, further research is needed to determine if disparities exist in the quality of care received, an important indicator not measured in this study.

Despite these limitations, this study addresses gaps in the current literature that enhance our understanding about community-dwelling frail elders in several ways. First, it provides an examination of multiple outcomes in a home- and community-based health care setting. Prior research on the crossover effect found among Black and White elders has been largely limited to mortality outcomes, whereas the present study examined a variety of physical and psychological outcomes. Second, the current study builds on past efforts to study physical and psychological functioning outcomes among minority elders by expanding comparisons beyond Black and White populations. The inclusion of Asian and Hispanic elders to the analysis revealed that these two minority groups may face a greater risk of decline in physical functioning through their course of home health care than previously known. Third, by focusing specifically on home health recipients who have been discharged to self-care, the study targets the oldest-old in the community who have a greater risk for requiring formal health care services, compared with the general population. Of particular interest was the availability or lack of supportive assistance experienced by these frail elders—specifically the 15% who had no formal or informal support whatsoever once discharged from their primary home health care provider. Black elders in this study were significantly more likely than any other group in the sample to be left to self-care without any support, despite past research describing Black adults as having stronger beliefs in the importance of filial responsibility (Sudha & Mutran, 1999). Among the Black elders in particular, the lack of informal support represents an increased risk for isolation and home confinement (Shaughnessy et al., 1994), and it has been associated with greater need for formal health care (Cagney & Agree, 1999). Given that access continues to be a critical focus of national efforts to address disparities in care provision, policymakers and service providers alike should recognize that even patients who have obtained access to services may still face barriers to gaining the care they need after they have been discharged from the health care system.

	Footnotes

 
This research was funded by The Jacob and Valeria Langeloth Foundation with supplemental support from the Visiting Nurse Service of New York. An earlier version of this paper was presented in October of 2001 at the annual meeting of the American Public Health Association, Atlanta, GA. We thank the anonymous reviewers for their insightful comments on an earlier draft of this manuscript.

¹ Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY.

Decision Editor: Laurence G. Branch, PhD

Received for publication July 22, 2002. Accepted for publication September 16, 2002.

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