Utilizing consumer-directed care for community-dwelling older adults : a supply-side and demand-side examination

Abstract

Background and Objectives: As a crucial service model for delivering public home- and community-based care, consumer-directed care (CDC) grants older people both choice of and control over service arrangements. Studies have shown that CDC services yield positive care outcomes, including improved health status and quality of life, especially for middle-class clients. However, the take-up of CDC programs is relatively low. The present thesis contributes to CDC utilization and policy implementation research by exploring supply-side and demand-side barriers. Three studies are included to achieve three objectives: 1) develop a cross-national framework on CDC policy designs for older persons; 2) investigate clients’ preferences for policy designs that promote consumer direction in a collectivist cultural setting; and 3) explore the impact of demand-side psychosocial factors guided by behavioral economics theories on CDC utilization and the relative importance of each factor. Research Design and Methods: Study 1 used cross-national document analysis to analyze 11 CDC programs from seven selected countries (the United States, the United Kingdom, Germany, the Netherlands, China, Australia, and Spain). An expert survey (n = 20) was conducted to gauge the importance of 14 policy indicators. Policy features were compared across programs using descriptive statistics and graphical approaches. Study 2 collected qualitative data through interviews with older Chinese (n = 6) and family members (n = 18) from Guangzhou, and analyzed the data using inductive thematic analysis. Study 3 conducted a district-representative cross-sectional telephone survey of older people (n = 417) who use public in-home services in Guangzhou. Multivariate logistic analysis with sampling weight was used. Results: Study 1 found the two most commonly used policy designs were mandatory provision of information about programs and care workers, and allowing older adults to quit CDC freely. The least commonly used policy designs were allowing a mixed model that combines CDC and conventional agent services, offering representatives when family members are absent, requiring criminal background checks for care workers, and empowering older adults to flexibly purchase all care-related goods. Study 2 revealed CDC service users’ perceptions of six themes within two domains. The first domain, benefit utilization, includes the need for: 1) flexibility in selecting care workers, despite the conflict between family direction and consumer direction; 2) autonomy in choosing budget management agents; 3) flexibility in selecting care-related goods; and 4) an adequate and equitable benefit amount. The second domain, professional support, includes the need for: 1) information and support; and 2) individualized training for care workers. Study 3 suggested the top three factors influencing CDC utilization: procedural literacy, hassle costs, and social norms toward CDC. Respondents with low procedural literacy were less inclined to use CDC, while hassle costs were

positively associated with CDC utilization. Those who perceived stronger norms toward CDC were more likely to use such services. Discussion and Implications: Study 1 provides a systematically operationalized framework to investigate CDC policy designs. The findings advance our understanding of CDC policy features from a cross-national perspective. Study 2 found that in collectivist cultural contexts, in-home services prioritize family rather than client welfare and preferences. Meanwhile, similar to individualistic cultural settings, clients and family members in collectivist cultural contexts desire autonomy and choice in service arrangements. Study 3 reveals nuances and complexity in the care decision-making process, and that people are not unboundedly rational when making decisions. Policymakers can empower older people and amend policy designs to local conditions by referencing findings from international experiences, the comprehensive CDC policy design framework, and six policy themes derived from clients’ experiences. Policymakers or practitioners can also employ cost-effective tools suggested in this thesis to facilitate CDC utilization and optimize resources to address the most crucial barriers in service utilization when budgets are constrained.