who are greatly or extremely impaired in Cleveland, Ohio, can be found in appendix II. Further, information on the services these people received has been collected in 2 phases over 1.5 years from 118 agencies. In studying the well-being status of older people, we used a questionnaire developed by the Duke University Center for the Study of Aging and Human Development in collaboration with the Administration on Aging, the then Social and Rehabilitation Service, and the Health Resources Administration of HEW. Questions were asked about an older person's status in the following areas of functioning (1) social, (2) economic, (3) mental, (4) physical, and (5) activities of daily living. The older person's responses to questions during the interview were used to categorize his or her status as one of the following: excellent, good, mildly impaired, moderately impaired, severely impaired, or totally impaired. For example, the older person's physical health status was placed in the appropriate category on the following scale after considering his or her responses to 22 detailed questions on physical health: 1. In excellent physical health. 2. Engages in vigorous physical activity, either In good physical health. Only No significant illnesses or disabilities. 3. Mildly physically impaired. 4. Has only minor illnesses and/or disabilities Moderately physically impaired. Has one or more diseases or disabilities which Severely physically impaired. Has one or more illnesses or disabilities which 6. Totally physically impaired. Confined to bed and requiring full-time medical Although the responses showed a separate status for the five areas of human functioning, we wanted to consider the entire person or what we have defined as the impairment of the person. Therefore, we combined the status in each of the five areas to form the overall well-being of the individual as shown in the following groupings: Impairment level Unimpaired Slighly impaired Mildly impaired Moderately impaired Generally impaired Greatly impaired Very greatly impaired Extremely impaired Description based on five areas included in Excellent or good in all five areas of human functioning. Excellent or good in four areas. Mildly or moderately impaired in two areas or mildly or moderatly impaired in one area and severely or completely impaired in another. Mildly or moderately impaired in three areas and or mildly or moderately impaired in two and severely or completely impaired in one. Mildly or moderately impaired in four areas. Mildly or moderately impaired in three areas, and severely or completely impaired in another. Mildly or moderately impaired in all five areas. Mildly or moderately impaired in four areas To assure ourselves of the representativeness of our results, we compared our data from the first phase with national statistics and similar analyses done in Durham, North Carolina, by Duke University. To assist us in interpreting the results of our analyses in both the prior and current reviews, we used consultants from the fields of gerontology and operations research. Comparison of the data in Cleveland with similar data gathered in Durham, North Carolina, showed the two samples were similar. The results of the two studies showed both populations were similar in demographic characteristics and individual functional areas. Further, the status and distribution by impairment level of older persons in Cleveland and Durham were similar. Using the questionnaire responses, we combined the separate status for the five areas into the following seven groupings: (1) unimpaired, (2) slightly impaired, (3) mildly impaired, (4) moderately impaired, (5) generally impaired, (6) greatly impaired, and (7) extremely impaired. The greatly and very greatly impaired groupings used in our prior report were consolidated into the greatly impaired because we found that the overall impairment of people in these two groups were similar. Using the questionnaire and service information gathered during the first phase of the prior review, we (1) developed the services each person received, (2) determined the source that provided each service, and (3) determined an average usage at each of the seven impairment levels. We then contacted 27 Federal, State, local, and private agencies to discuss service costs and to gather cost data for the period October 1976 to March 1977. From this information, an average cost was developed for each service. These average costs appear reasonable in comparison to similar data from Chicago, Illinois, compiled by the Mayor's Commission on Aging, and Durham, North Carolina. To develop service costs for each impairment level we combined the four data elements: --Cost or value of each service. --Average usage of each service per month. --Percentage receiving each service from an agency. --Percentage receiving each service from family or The cost assigned to services provided by agencies and families and friends was calculated individually for each impairment level. The agency cost was calculated in terms of an average monthly cost per individual. This calculation included --percentage receiving service, --monthly frequency of use of the service, and --cost of service. The agency portion was mostly funded through Federal sources and included services provided to older persons by Government and private service providers. This process was repeated to determine the value of services provided by families and friends. In the absence of family and friends, any services received would have to be from an agency. Therefore, we assigned the same cost to family and friend services that we found for agencies. The two service costs (agency, family and friends) were added to determine the total cost or value of services provided at each impairment level. The total service costs were plotted by impairment level. The resulting curve was compared to the cost on institutionalization based on January to February 1977 reimbursements to skilled nursing and intermediate care facilities in Ohio. COST COMPARISON In comparing the costs to maintain older people in their homes versus an institution, we first analyzed each situation separately. The first group we analyzed was noninstitutionalized people (about 95 percent of persons 65 years or over). The second group was institutionalized people. We then compared the costs for both groups to determine at what impairment level the total cost to keep an older person at home (including the value of the service provided by family and friends) equals the cost to institutionalize the person. While we do not believe that a decision to institutionalize an individual who wants to remain at home should be based on cost comparisons alone, we believe that these comparisons provide some insight as to the economic, physical, and social factors which have influenced such decisions. Noninstitutionalized people Several factors contribute to a person's ability to exist outside an institution. One is the level of impairment. People who are more impaired receive more services than people who are less impaired. As the table below shows, transportation, checking (periodic monitoring by telephone or personal contact), and social and recreational services are received by the less impaired. At the more impaired levels, social and recreational services drop drastically while nursing care, personal care, and continuous supervision increase significantly. Eventually the most severely impaired people require almost constant care. |