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Correspondence: Address correspondence to Adam Atherly, PhD, Department of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Rd. NE, Atlanta, GA 30322. E-mail: aatherl{at}sph.emory.edu
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Abstract |
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Key Words: Managed care • Frail elderly • Satisfaction
Although there are a multitude of satisfaction scales for health plans, hospitals, and ambulatory-care settings, most scales have been designed for and validated on nonelderly populations (Smith, 2000). Scales developed on younger, healthier populations may not apply equally well to older populations, especially those who are quite frail (Applebaum, Straker, & Geron, 2000; Kleinsorge & Koenig, 1991; Pearson, Hocking, Mott, & Riggs, 1993; Sikorska, 1999; Zinn, Lavizzo-Mourey, & Taylor, 1993). In comparison with younger adults, older adults are generally more satisfied with their health care (Owens & Batchelor, 1996; Pope & Mays, 1993). This may be because they have different experiences with the health care system or lower expectations about treatment effectiveness. For example, older adults are more likely to contact the health care system because of poor health and chronic illness. This increased contact may provide greater context with which to judge care (Kasper & Riley, 1992), but it might also provide an incentive for dependent elderly patients to rate care more favorably (Owens & Batchelor, 1996). In addition, many older adults view their deteriorating health as normal, and their satisfaction with care could be the result of having lower expectations concerning the effectiveness of treatment (Kasper & Riley, 1992).
Further, the relevant dimensions of satisfaction for older adults may differ from those for other groups, with older patients having more specific concerns about special care for serious problems and difficulty traveling (Cryns, Nichols, Katz, & Calkins, 1989). Aging is also associated with health-related life changes, including changes in living arrangements (e.g., moving into a nursing home or assisted living facility). Compared with the care offered in other settings, such as acute care during a physician office visit, care provided in the home or in a long-term-care facility often involves the use of less technology from personnel with more limited training (Kane & Kane, 1988). Consequently, satisfaction measures should differ depending on the settings (e.g., hospitals, nursing homes, home care, or outpatient services) because the relevant domains for satisfaction measurement may differ substantially for acute and long-term-care services (Geron et al., 2000). So, although scales intended for use in younger populations may be used on older adults, instruments specifically designed for the elderly population in long-term-care settings are likely to have superior specificity and responsiveness.
An additional challenge in assessing satisfaction in elderly persons is that many individuals are unable to respond to questionnaires. Past studies have found that between 60% and 80% of institutionalized elderly people suffer from some degree of cognitive impairment (Harper, 2000). For severely cognitively impaired individuals, it is not possible to assess satisfaction directly. In the absence of an adequate alternative to direct assessment of individuals, it may be informative to interview a family member. Although family members do not substitute for the patient, they provide important additional information (Lavizzo-Mourey et al., 1992; Schnelle et al., 1999). In particular, family-member interviews provide the opportunity to evaluate aspects of care that may be unknown to the patient (e.g., the relative burden placed on family members by the health care system; see Cryns et al., 1989).
In a maintenance setting, such as long-term care, the importance of providing satisfactory care may become even more pronounced. Some initial efforts have been made to develop appropriate instruments for nursing home residents (Zinn et al., 1993), including those with cognitive impairments (Norton, van Maris, Soberman, & Murray, 1996), or their surrogates (Kleinsorge & Koenig, 1991). Several surveys measuring satisfaction have been produced by associations and other interested parties such as state governments, such as the survey developed by the state of Ohio to measure satisfaction in nursing homes for residents and families (Ohio State Department of Aging, 2003). In addition, the Agency for Healthcare Research and Quality is developing a nursing home version of the Consumer Assessment of Health Plans Survey (CAHPS). A satisfaction measure for home care has also been designed for frail older adults that uses five types of home care services (e.g., home health aide, case management; see Geron et al., 2000). Existing surveys measuring satisfaction with health plans include the Medicare version of the CAHPS (Hays et al., 1997), although CAHPS focuses more on the measurement of use of services rather than on elements directly related to patient satisfaction.
The Program for All-Inclusive Care of the Elderly (PACE) is designed to serve a population of frail older adults, who are eligible for both Medicare and Medicaid coverage and who are deemed to be eligible for nursing home care but are still living in the community (Eng, Pedulla, Eleazer, McCann, & Fox, 1997; Kane & Blewett, 1993). PACE places a strong emphasis on teamwork and provides active primary care around a base in adult day health care. The PACE program is designed to provide a comprehensive set of services for its population and is intended to be integrated and client centered (Kane, 1999). Families are actively involved in the PACE program, particularly in the care-planning process.
The PACE Satisfaction Survey contributes to this nascent literature in several ways. First, the PACE Satisfaction Survey was developed and tested on a frail, elderly population. This population, being both high cost and unusually vulnerable to adverse health events, is particularly important for the health care system. Second, the PACE Satisfaction Survey separately surveys family members. For elderly populations, dementia and other forms of incapacitation often render the patient unable to respond to surveys. To our knowledge, there are no existing surveys that evaluate family-member satisfaction with capitated care for older adults. Finally, the survey is designed for the evaluation of care for a capitated population under a program that addresses both acute and long-term care. With capitation, health care providers are expected to substitute away from high-cost care and toward low-cost care (e.g., providing some care in an outpatient rather than inpatient setting). Issues of underutilization, such as provider reluctance to hospitalize, become increasingly important in a capitated setting and have been directly incorporated into the PACE Satisfaction Survey.
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If the individual was unable to complete the survey, a separate survey was administered to someone close to the individual, such as a family member. Because it was expected that the domains of satisfaction would be different for the participants and family members, separate instruments were developed. Both surveys were administered in face-to-face interviews. A total of 402 interviews were completed at 11 PACE sites. Of the 402 surveys, 153 were completed by PACE participants, 112 were completed by non-PACE individuals, 82 were completed by PACE family members, and 55 were completed by non-PACE family members. Both the PACE and non-PACE individuals had high rates of chronic illnesses, including arthritis (74%), high blood pressure (62%), stroke or its aftereffects (35%), and diabetes (37%).
The satisfaction survey was a piece of a larger evaluation of the PACE program. The satisfaction survey was administered 18 months after the initiation of the evaluation. Of the 666 individuals eligible for evaluation, 529 (79.4%) completed some portion of the evaluation, and 402 completed the satisfaction survey (60.3% of the entire sample and 76.0% of those completing any part of the evaluation). Of those that did not complete any portion of the evaluation, the most frequent reason was inability to locate the client (42), followed by refusal (41) and client impairment (21).
Item Selection and Development
There is no universally accepted conceptual model for patient satisfaction (Smith, 2000). Typically, the term patient satisfaction refers to an individual's satisfaction with health care that the individual has received directly (Geron et al., 2000). Previous research suggests that satisfaction is both unidimensional (i.e., that patients make overall summary judgments) and multidimensional (Abramowitz, Cote, & Berry, 1987; Aharony & Strasser, 1993; Meterko, Nelson, & Rubin, 1990). This multidimensionality has led many researchers to create separate scales to measure satisfaction with more specific aspects of medical care, including such areas as provider's interpersonal skills and access to services (Hulka, Zyzanski, Cassel, & Thompson, 1970).
This lack of a widely accepted conceptual model complicates the development of scales measuring patient satisfaction and results in variations of the included domains of satisfaction from study to study, depending on the particular population, setting, and aspect of health care of interest. Many individual sociodemographic characteristics influence patient satisfaction—including prior health status and expectations about care—in addition to the structure, process, and outcomes of care (Aharony & Strasser, 1993; Cleary & McNeil, 1988). In addition, satisfaction scales tend to be strongly skewed toward positive ratings, so satisfaction scales must be designed to distinguish between providers offering similar services (Williams & Calnan, 1991).
Previous research has suggested that the structure of care, including both organization and financing, influences satisfaction. HMO arrangements have been found to have higher satisfaction because of lower cost sharing (Cleary & McNeil, 1988), although patients have also been found to have greater satisfaction in organizations with more provider autonomy (Greenley & Schoenherr, 1981). Important provider characteristics affecting patient satisfaction include factors such as nursing care, the quality of food, noise levels, and physical surroundings (Doering, 1983). Several published studies have also suggested that greater accessibility, availability, and continuity of care increase satisfaction (Cleary & McNeil, 1988).
Among published studies measuring satisfaction in long-term care settings, there is no widely agreed upon set of domains. The Long-Term Care Satisfaction Survey (LTCSS) identified seven domains (plus global satisfaction): autonomy, living area, laundry, food quality, activities, staffing, and dignity (Norton et al., 1996). The Nursing Home Resident Satisfaction Survey (NHRSS) identified three quite different domains (plus global satisfaction): physician services, nursing services, and environment (Zinn et al., 1993). The Nursing Home Customer Satisfaction Scale (NHCSS) identified six domains: nursing–aide, administration, staff empathy, food, housekeeping, and home issues (Kleinsorge & Koenig, 1991). The Ohio State Nursing Home Resident Satisfaction Survey identified eight domains (plus overall satisfaction): activities, administration, choice, direct care and nurse assistants, environment, laundry, meals and dining, and social services (Ohio State Department of Aging, 2003). Ten domains were similarly identified by the state of Vermont, including admissions, room, dining, maintenance, nurses, nurses' aides, housekeeping, activities, and finances (Vermont Department of Aging and Disability, 2001).
Few published surveys were designed to measure satisfaction in long-term-care settings other than nursing homes. The Home Care Satisfaction Measure (HCSM) identified eight domains within five service areas (satisfaction with homemaker, home health aide, case management, home-delivered meals, and grocery): competency, humaneness, dependability, service adequacy, continuity of care, choice, accessibility, and advocacy (Geron et al., 2000). The Home Care and Terminal Care Satisfaction Scale (HCFC), focusing on home care, used nine domains (plus a global satisfaction measure): availability of care, continuity of care, physician availability, physician competence, personal qualities of physician, communication with physician, involvement of patient and family in treatment decisions, freedom from pain, and pain control (McCusker, 1984).
Although the existing surveys are not directly comparable with the new PACE survey—the PACE survey is intended to measure satisfaction for frail elderly persons in an environment where care is integrated and financing is capitated—the populations and some key issues should be similar. The hypothesized domains included elements that were believed to be important to either the PACE users themselves or their families. Moreover, they were intended to represent characteristics and concerns that would be important to the care of frail older persons generally. On this basis, we hypothesized four domains: perceived access to medical care, perceived technical quality of medical care, perceived interpersonal quality, and decision making.
These domains differ from the published literature cited herein, largely because we believed the relevant domains for our population in the PACE setting would be different. However, there are certainly similarities. Several of the surveys in this area have some measure of the individual's control over his or her environment or respect for the individual (termed variously autonomy, staff empathy, involvement of patient and family in treatment decisions, resident's rights, and choice). We also expected a domain along those lines, which we termed decision making.
Similarly, several surveys include measures of the patient's perception of the medical care he or she received (termed physician services, nursing services, nursing–aide, home health aide, availability of care, continuity of care, physician availability, and physician competence). Because the medical care component was so important for our frail population, two of our hypothesized domains cover this area: perceived access to medical care and perceived technical quality of medical care. Although we hoped these would prove to be separate domains, previous literature suggests that patients have difficulty distinguishing technical quality of care from interpersonal care (Davies & Ware, 1988).
Finally, we included a domain measuring perceived interpersonal quality. This corresponds roughly to domains such as dignity, staff empathy, humaneness, and personal qualities of the physician. This domain was intended to tap components of care that are beyond mere access and quality but that instead involve issues such as the friendliness of the staff. Both patient perceptions of the technical quality and interpersonal care have been found to be related to satisfaction, although interpersonal and communication skills appear to be more important for satisfaction ratings (Cleary & McNeil, 1988; Doering, 1983; Nelson-Wernick et al., 1981).
We selected these domains on the basis of the existing literature plus our discussions with PACE staff and administrators in the absence of any directly applicable surveys in the published literature. Hence, although our selection of domains was guided by the previous research, this study should be considered more of an exploratory analysis than a confirmatory analysis with strong a priori expectations.
One limitation we faced is that we were restricted to 24 items in the satisfaction survey. The survey was part of a larger PACE evaluation, funded by the Centers for Medicare and Medicaid Studies (then the Health Care Financing Administration). Items were initially selected based on our review of the literature on patient satisfaction in general, and long-term care in particular, plus the opinions of an expert panel formed to identify key elements of patient satisfaction in our population. This resulted in an initial survey that was sent to the program coordinators of the 11 PACE sites for evaluation. Following this consultation, we had identified a series of performance attributes that we judged captured the essence of PACE care.
Scoring
Each of the 23 items in the participant survey was scored with a 5-point Likert scale (Streiner & Norman, 1995). A score of 1 corresponded to strong agreement with a positive statement about the program, such as "I can see a doctor whenever I need to." Conversely, a score of 5 indicated strong disagreement with the statement (copies of the survey are available from the authors). Hence, a lower score implies a superior rating. Five items in the survey utilized reverse coding; for these questions, the scoring scheme in the survey was reversed for the purposes of analysis. Respondents to the survey had difficulty answering seven of the questions. (The questions were as follows: "The program expects my family and friends to provide a lot of help," "The staff has discouraged me from using certain types of care," "Medical staff should put people in the hospital more often," "I feel pressured to say I don't want certain kinds of care," "I enjoy going to day care," "I enjoy being with the people I meet at day care," and "I would like to go to day care less often.") For these items, more than 10% of the sample answered "don't know," and the items were omitted from the analysis. Similar to respondents to the participant survey, respondents to the family-member survey had difficulty responding to certain items. More than 10% of the family members responded "don't know" to the items about the appropriateness of hospitalizations ("The people who provide my __ health care don't send people into the hospital when they should" and "The people who provide my __ health care should put more people in the hospital than they do"), nursing home care ("Because of the people who provide my __ health care, I do not need to place my __ in a nursing home" and "The people who provide my __ health care will not admit people to nursing homes even when it is needed"), and day care ("My __ enjoys going to the day health center"). In addition, an item asking about discussions between the patient and his or her doctor regarding what to do if the patient's heart stops or is otherwise incapacitated also had more than a 10% response of "don't know" ("My __'s doctors have had helpful discussions about what __ wants to do if __ heart stops or if __ cannot make decisions"). All 6 of these items were omitted from the analysis.
The scoring scheme was identical to the participant survey. Each of the items on each of the scales was scored on a 1 to 5 basis. A score of 1 corresponded to strong agreement and a score of 5 corresponded to strong disagreement. A lower score therefore implies a superior rating. Seven items in the survey utilized reverse coding.
Analysis
The satisfaction literature discussed previously has established that satisfaction is a multidimensional concept; that is, that within the overall framework of satisfaction, there are a series of independent subelements. One standard approach for making inferences about the underlying factors (the factor structures) from observed data is to use factor analysis. Factor analysis uses covariation between variables to identify groupings of variables.
Factor analysis can either be confirmatory, in which the data is used to confirm previously established relationships, or exploratory, in which the relationships between the variables are established by the data. Although we did have expectations regarding how the variables would load, there was little existing literature on our population (the frail elderly population) in this setting (coordinated care), so our analysis should be regarded as being closer to an exploratory factor analysis than a confirmatory factor analysis. The analysis utilized a promax oblique rotation, which creates a relatively simple factor structure in which the factors are allowed to be correlated with one another. Each of the scales was tested for internal consistency with Cronbach's coefficient alpha.
To assess the external validity of the scales, we calculated the mean satisfaction scores for PACE participants at each site and then correlated them with measures of the mean quality of care for eight sites where such data had been collected under another project. We obtained the quality-of-care measures from a separate study that specifically assessed the quality of care for the PACE program (Pacala, Kane, Atherly, & Smith, 2000; Smith, Atherly, Kane, & Pacala, 1997). In brief, trained experts reviewed medical records and then made judgments regarding the quality of care. Each of the quality-of-care measures was scored on a 1–5 Likert-type scale. The three measures were overall management (which ranged from 1, very good, to 5, very poor), overall quality of care (range: 1, extreme, above standard, to 5, extreme, below standard), and whether the person would send his or her closest relative to the team at this PACE site (range: 1, definitely yes, to 5, definitely no). These measures have been found to discriminate among sites effectively (Pacala et al., 2000). Because different individuals were sampled in the satisfaction study than in the quality-of-care study, it is not possible to compare the satisfaction and quality measures directly.
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The final factor is Decision Making. Both of the items loading onto this factor are related to the patient's decisions about his or her care. From these three factors, scales were created using a weighted summation of the items that loaded onto each factor, with the factor loadings serving as weights.
Reliability
The calculated Cronbach's alphas were within the desired range for two of the scales (Perceived Access and Perceived Interpersonal Quality). The highest internal consistency was achieved by the Perceived Access scale, with a score of 0.88. The alpha for the Perceived Interpersonal Quality factor was 0.74, well within the acceptable range. The alpha for Decision Making demonstrated poor internal consistency (
= 0.54), reflecting the small number of items that loaded onto that scale.
Validity
Satisfaction, as defined by consumers, and quality of care, as defined by health care professionals, are related but not identical concepts. Therefore, we expected only a moderate degree of correlation between these measures. We hypothesized that the Perceived Access scale should have the strongest correlation with measures of quality of care because its items all relate to participants' judgments regarding their direct health care. Perceived Access, Perceived Interpersonal Quality, and Decision Making scales were all positively correlated with the measures of quality of care (Table 2). As we expected, the highest correlation was between Perceived Access and overall management. The small sample size for this analysis (n = 8) limits the value of statistical significance testing, although most correlations were marginally statistically significant.
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The five items in the second factor all revolve around family issues and the ability of the family to actively participate in the health care of the participant to the degree the family feels is appropriate. This factor contains issues of families' ability to speak to health care providers and the burden placed on families by providers. This factor is designated Family Pressure.
Factor 3 deals less with access or quality than with the user friendliness of the system. Items look at such issues as getting help at home, relieving burdens on families, seeing providers easily, and having coordinated care. This factor is designated Ease of Access. The Ease of Access factor is closely correlated with the Perceived Access factor, with 
=.52.
The fourth factor contains two items that revolve around the system's ability to involve families in the care process. It is designated Family Involvement.
Reliability
Using the results of the factor analysis, we created four scales, with the factor loadings serving as the weights. We tested each of the four scales for internal consistency by using Cronbach's coefficient alpha. The coefficients for the Perceived Access ( = 0.89), Family Pressure ( = 0.90), and Ease of Access ( = 0.88) scales are all high. The alpha for the Family Involvement scale is marginal ( = 0.64).
Validity
We correlated the four family-member satisfaction scales with the same three quality-of-care measures as the participant scales to assess external validity. We expected that the Perceived Access scale would have the highest correlation with the quality-of-care measures, because the items query the respondents' perceptions of the quality of care. We expected Ease of Access to also be correlated with the quality-of-care measures, with a weaker association for the Family Pressure scale. No association was expected between quality of care and Family Involvement because this scale taps family members' perceptions about the effect of the system on the family, not the individual.
Three of the four satisfaction scales were positively correlated with measures of quality of care (see Table 5). The Perceived Access scale was correlated with mean site-level scores for overall management ( = 0.728, p =.063), with positive but insignificant correlations with overall quality of care ( = 0.608, p =.147) and willingness to send relatives ( = 0.493, p =.261). The Ease of Access scale was positively correlated with all three quality-of-care measures, although the results lacked significance. The Family Involvement scale was positively and significantly associated with overall management ( = 0.737, p =.058) and willingness to send relatives ( = 0.759, p =.047) and positively but insignificantly associated with overall quality of care ( = 0.419, p =.349). As expected, the Family Pressure scale was not significantly associated with any of the quality-of-care measures.
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The PACE Satisfaction Survey has several strengths. It was specifically designed for use in a capitated population. Because underutilization is a potential concern with capitated care, items were developed and included to address this issue. It also incorporates a separate family-member survey. Many frail elderly patients are unable to respond to surveys, and family members provide an important source of additional information, including aspects of care that may be unknown to the patient (Schnelle et al., 1999). It is useful to measure family members' opinions in their own right, but the differences in factor structure underlines the dangers in using family members as proxies for the enrollees themselves.
Although the scales identified in the participant survey are somewhat different from our a priori expectations, they are similar to those in the literature. Our hypothesized perceived access to medical care and perceived technical quality of medical care largely combined into the perceived access to medical care dimension. The perceived interpersonal quality and decision making scales were largely as expected. Looking at previous literature, we find that perceived access roughly corresponds to staff service (from the Nursing Home Resident Satisfaction Survey), perceived interpersonal quality corresponds to empathy (from the Nursing Home Customer Satisfaction Scale), and decision making taps latent concepts similar to autonomy and dignity (from the Long-Term Care Satisfaction Survey). The participant survey thus reinforces the findings of previous work in this area.
As expected, the dimensions of satisfaction found in the family-member survey did not match the dimensions found in the participant survey. Identical items in the two surveys loaded onto different factors, and the scales focus on different issues. Although both surveys include a Perceived Access scale, the other three scales in the family-member survey (Ease of Access, Family Involvement, and Family Pressure) have no corresponding scales in the participant survey. This suggests that family members do represent an additional perspective on participant care.
Both participant and family-member surveys were limited in their ability to discriminate between PACE and non-PACE individuals. The participant survey did find significantly higher satisfaction on the Perceived Interpersonal Quality scale and the Decision Making scale, which is consistent with the goals of the PACE program. These differences may reflect superior coordination of care in the PACE program. Although PACE would be expected to increase satisfaction on all participant scales, the concentrated team efforts on clients would be expected to have their greatest payoff on the Perceived Interpersonal Quality and Decision Making scales. Satisfaction was also higher for the PACE group on the Perceived Access scale, although the difference was not statistically significant.
On the family-member survey, satisfaction was virtually identical between PACE and non-PACE on the Family Pressure and Family Involvement scales (with the mean scores being within 0.10 points). Larger differences, albeit statistically insignificant, on the other scales both indicated superior satisfaction in the PACE program. This result does not appear to be due to a lack of variation in the responses by the participation or a ceiling effect; the coefficient of variation for three of the family-member scales are larger than the coefficient of variation for either of the participant scales, and all scales exhibit adequate variation. (The coefficient of variation for the family-member scales are as follows: 26.6 for Perceived Access, 53.7 for Family Pressure, 44.5 for Ease of Access, and 48.6 for Family Involvement; for the participant scales it is 39.6 for Perceived Access and 38.7 for Perceived Interpersonal Quality.) The lack of difference between PACE participants and non-PACE individuals was not unexpected given that the PACE program is largely client centered (as opposed to family centered). Although the PACE program makes an active effort to involve families, family members do not have the same level of contact with the program as the participants themselves. Finally, it is important to note that the non-PACE individuals were eligible for PACE, and they were offered PACE services, but declined. It is possible that the non-PACE individuals declined services because their families were better equipped to provide care. For these reasons, the similarity in satisfaction scores may reflect similar satisfaction in the two groups.
This tool represents an initial effort to develop a satisfaction survey for a high-cost frail elderly population enrolled in a program specifically designed to contain costs and increase quality. As efforts continue to integrate all aspects of health care delivery and health care financing, the emphasis on cost-effective care for high-cost populations will continue to grow. It is important that measurement tools continue to keep pace by encompassing the entire range of outcomes of care, including patient satisfaction.
Further research is needed to refine measures that transcend settings. The PACE Satisfaction Survey is directed toward a nursing home certifiable population living in the community; therefore, its dimensions of satisfaction are appropriate to a model that includes active primary care and day care, but not housing and board. Nothing is known about its applicability in other settings, a limitation that should be addressed in the future. The need to understand how measures apply to different settings is a general issue for satisfaction measures. For example, the current work to develop a nursing home version of the CAHPS could be expanded to address issues that are applicable to related settings, such as assisted living. However, no satisfaction measure is likely to capture all dimensions in all the varied settings where care is provided to the elderly population.
In addition, more research is needed to understand how elements of care and elderly consumer expectations influence consumer satisfaction. Although satisfaction is often considered an aspect of quality, research should further address the relationship between satisfaction and the processes and outcomes of care. This would facilitate a greater understanding of the implications of high and low consumer satisfaction.
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1 Department of Health Policy and Management, Emory University, Atlanta, GA.
2 Division of Health Services Research and Policy, University of Minnesota School of Public Health, Minneapolis.
3 Department of Population Health Sciences, University of Wisconsin—Madison Medical School, Madison.
Decision Editor: Linda S. Noelker, PhD
Received for publication October 1, 2002. Accepted for publication July 18, 2003.
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