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The Economic and Social Review, Vol. 20, No. 3, April, 1989, pp. 219-241

The Placement of Elderly Persons: A Logit

Estimation and Cost Analysis*

E A M O N O ' S H E A

University College, Galway

R O S A L E E N C O R C O R A N

Eastern Health Board, Naas, Co. Kildare

Abstract: This study focuses on two groups of elderly persons deemed by the relevant health profes­

sional to be on the margin of domiciliary care and institutional care, respectively. A logit regression is estimated in order to test for significant factors that may be important in determining the current placement of those elderly persons. The formal and informal costs of care are enumerated and valued, in monetary terms, for the domiciliary based group. Some suggestions are made with regard to current and future placement decision-making for elderly persons. I n particular, it seems increasingly inappro­ priate to treat informal care as a free good given the range of opportunity costs identified by carers.

ery l i t t l e is k n o w n about the cost effectiveness o f different regimes o f V care for the elderly i n I r e l a n d . There are no comprehensive studies o f the disability levels o f elderly persons either i n residential facilities or living i n the c o m m u n i t y . Neither is there m u c h i n f o r m a t i o n about the range o f f o r m a l services available or the cost o f p r o v i d i n g these services for elderly persons. There is especially a dearth o f quantitative evidence o n the extent o f i n f o r m a l caring i n the c o m m u n i t y . A l l o f these issues relate crucially to balance o f care considerations for elderly persons. The a priori expectation i n this regard is that elderly persons w h o are least dependent live at home i n the c o m m u n i t y ; those w h o are most heavily dependent are usually cared for i n l o n g stay geri­ atric i n s t i t u t i o n s . The most interesting elderly group are, therefore, those o f intermediate dependency, w h o are o n the margin between d o m i c i l i a r y and i n s t i t u t i o n a l care. O f course i t is more correct t o discuss care o f the elderly

*We are very grateful to John Blackwell, Karen Gerard, Cam Donaldson, Richard Breen and two anony­ mous referees for helpful comments on earlier drafts of this paper.

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i n terms o f a c o n t i n u u m o f care encompassing respite care, day care, sheltered housing as w e l l as the t r a d i t i o n a l d o m i c i l i a r y and long stay regimes. Neverthe­ less, i m p o r t a n t insights can be gained b y concentrating on d o m i c i l i a r y versus long stay care for marginal elderly. This is p a r t i c u l a r l y the case i n I r e l a n d where the c o n t i n u u m o f care for elderly persons is o n l y beginning t o take shape and where decision-making i n most health board regions is c o n f i n e d t o a choice o f either d o m i c i l i a r y or long stay i n s t i t u t i o n s .

The current reality, i n this c o u n t r y , is t h a t long stay geriatric beds are being reduced. I n s t i t u t i o n a l care is, as a result, l i k e l y to become less available for elderly persons, especially long stay in-patient care. Decision-making w i t h regard to placement must, therefore, ensure that only the most deserving elderly are allocated t o i n s t i t u t i o n a l beds. Y e t , so l i t t l e is k n o w n about the decision t o place an elderly person i n an i n s t i t u t i o n , either h o w such decisions are arrived at and/or w h a t are the characteristics o f the elderly person that makes i n s t i t u t i o n a l i s a t i o n a necessity. A n y decision n o t to institutionalise an elderly person raises the related issue o f the adequacy o f b o t h s t a t u t o r y and i n f o r m a l care i n the c o m m u n i t y . There are at present, according t o the N a t i o n a l Council for the Aged, an estimated 6 6 , 0 0 0 elderly persons i n the c o m m u n i t y w h o require some level o f care; 36 per cent o f those require a l o t o f care ( N a t i o n a l C o u n c i l for the Aged, 1988). Far t o o often the case for c o m m u n i t y care is made w i t h o u t e x p l i c i t consideration of the adequacy of existing statu­ t o r y services or the real cost o f i n f o r m a l care services p r o v i d e d b y the f a m i l y and friends o f the elderly person.

The question o f whether d o m i c i l i a r y care or i n s t i t u t i o n a l care is the most cost effective, and for w h o m , is l i k e l y t o become the d o m i n a n t care o f the elderly issue o f the 1990s. The objective o f this study is t o examine the characteristics o f elderly persons w h o have been i d e n t i f i e d as being o n the margins o f d o m i c i l i a r y and i n s t i t u t i o n a l care. The nature o f care, the cost o f s t a t u t o r y services and the extent o f i n f o r m a l care are examined for the d o m i ­ ciliary group. A l o g i t m o d e l is estimated i n order t o i d e n t i f y variables t h a t m a y be significant i n d e t e r m i n i n g whether a selected elderly person is l i k e l y t o be cared for at home or i n an i n s t i t u t i o n . E l d e r l y persons included i n the study have been chosen b y the c o m m u n i t y physician w h o has p r i m a r y respon­ s i b i l i t y for the allocation o f elderly persons w i t h i n the particular c o m m u n i t y care area under observation. The q u a l i t y of care is assumed invariant between regimes o f care and the elderly persons are also assumed t o be indifferent between care i n either regime.

I I S E L E C T I N G P A T I E N T S A N D M E A S U R I N G D E P E N D E N C Y

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persons w i t h i n the particular c o m m u n i t y care area, d o m i c i l i a r y and institu­ t i o n a l based, c o u l d be i n c l u d e d i n the s t u d y .1 I t was decided that the most

practical approach was t o focus on those elderly w h o c o u l d be classified as either being on the margins o f d o m i c i l i a r y or i n s t i t u t i o n a l care. The, a priori, theoretical rationalisation for such an approach is illustrated i n Figure 1. A n y elderly person w i t h a dependency level far b e l o w D * ( l o w disability) has a d o m i c i l i a r y cost o f care structure less than that w h i c h w o u l d be i n c u r r e d i f that elderly person was cared for i n an i n s t i t u t i o n . For elderly w i t h depen­ dency levels m u c h above D * (high disability) the opposite is presumed t o be the case. Those elderly having most p o l i c y relevance are characterised b y a level o f dependency at or a r o u n d level D * . I f one assumes that q u a l i t y o f care and health status outcomes are n o t significantly different between regimes o f care decisions about placement o f elderly persons can therefore be made on the basis o f cost differences between regimes. O f course o f equal interest is the estimation o f crucial variables that w o u l d assist i n explaining w h y some individuals w i t h dependency levels at or a r o u n d D * are c u r r e n t l y being cared for i n i n s t i t u t i o n s while others w i t h the same level o f dependency are being cared for at home.

F i g u r e 1: The Relationship Between the Costs of Care and Dependency Category for

Domiciliary and Institutionally Based Elderly Persons

M C

.. M C 'D

0 ( L o w ) ) D * L E V E L O F D E P E N D E N C Y

(High)

M CD = Marginal cost of d o m i c i l i a r y care.

M C , = Marginal cost of i n s t i t u t i o n a l care.

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The m u l t i f a c e t e d nature o f disability and dependency i n elderly persons makes i t impossible, however, t o i d e n t i f y , i n practice, a cross-over ( D * ) level of dependency as i l l u s t r a t e d i n Figure 1. Neither is there a c o m m o n m u l t i ­ dimensional measure o f dependency that is u n i f o r m l y applied b y all physicians charged w i t h the placement o f elderly persons among different regimes o f care w i t h i n health boards. The wide differences i n rates o f i n s t i t u t i o n a l i s a t i o n for elderly persons among health boards p a r t l y reflects this heterogeneity o f dependency measurement among physicians ( R e p o r t o f W o r k i n g Party o n Services for the E l d e r l y , 1988). A v a i l a b i l i t y o f beds and general resource constraints are also, o f course, factors i n explaining general variation i n rates of i n s t i t u t i o n a l i s a t i o n .

The literature is o f l i m i t e d use t o those charged w i t h assigning levels o f dependency i n elderly persons. Simple, either tested or untested, ordinal scales take a fairly l i m i t e d approach t o measuring dependency. Wright et al. ( 1 9 8 1 ) , for example, u s e d a G u t t m a n Scaling, based o n the cumulative loss o f f u n c t i o n , m a i n l y o n physical activities o f daily living, by elderly persons. The scale p r o d u c e d coefficients for r e p r o d u c i b i l i t y and scaleability that were satisfactory for b o t h m e n and w o m e n and across forms o f care. There were of course elderly w h o d i d n o t correspond t o the scale. Wright suggested t h a t these non-scale types m i g h t be m a i n l y senile dementia patients. I n a sub­ sequent paper, however, K y l e , et al. (1987) applied an extended twelve i t e m G u t t m a n Scale t o m e n t a l l y i n f i r m patients and f o u n d that i t p r o v i d e d a reasonable f i t for the patients under observation. M e n t a l state items, such as problems w i t h m e m o r y , comprehension, c o m m u n i c a t i o n and confusion were felt t o be adequately reflected i n that they w o u l d give rise t o problems i n c a r r y i n g o u t the activities o f daily l i v i n g i n c l u d e d i n the scale.

The m a i n , p r o b l e m w i t h unidimensional scales is, however, this very w o r r y that i m p o r t a n t non-physical attributes o f incapacity are n o t p r o p e r l y assessed. Health professionals are quick t o p o i n t o u t that many factors other than physical dependency are i m p o r t a n t i n balance o f care considerations for elderly persons. This is o f course correct. Behavioural, social, m e n t a l and e m o t i o n a l problems are all elements o f a complete index o f incapacity. There are, however, complexities i n m o v i n g f r o m unidimensional t o m u l t i d i m e n ­ sional indices. The m a i n issues revolve around the c o m b i n i n g o f o r d i n a l measurements o f physical distress w i t h other measurements o f incapacity. Assuming, for example, that we c o u l d get agreement o n an ordinal scaling o f b o t h physical and behavioural dimensions o f incapacity h o w w o u l d these indices be c o m b i n e d t o provide meaningful and consistent measurements? Figure 2 illustrates the p r o b l e m .

There is no d o u b t that an elderly person ( X ) w i t h behavioural incapacity XB and physical dependence Xp is more disabled than an individual ( Y ) w i t h

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wants t o compare i n d i v i d u a l ( X ) w i t h i n d i v i d u a l ( Z ) . I n d i v i d u a l ( X ) repre­ sents greater behavioural incapacity b u t l o w e r physical incapacity t h a n i n d i ­ v i d u a l ( Z ) . H o w , therefore, should one trade o f f behavioural and physical incapacity? The dynamics o f such trade offs are n o w being investigated w i t h i n the f r a m e w o r k o f the " q u a l i t y adjusted life y e a r " research programme. H o w ­ ever, this research is at an early stage and i t w i l l be a while before disparate measures o f health status can be satisfactorily c o m b i n e d or q u a n t i t a t i v e l y measured. I n the meantime as Wright (1986) makes clear, all present scales have some drawbacks; the best way f o r w a r d is t o use the most appropriate measure for the task i n h a n d b u t t o be e x p l i c i t i n o u t l i n i n g all o f the measure's l i m i t a t i o n s .

F i g u r e 2: Measuring Self-health: Combining Physical Incapacity and Behavioural Incapacity

H i g h

I N D E X O F B E H A V I O U R A L I N C A P A C I T Y

0 L o w

1

I N D E X O F P H Y S I C A L I N C A P A C I T Y

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One c o m m o n approach w h i c h has sought t o circumvent the above problems is to use aggregated c a r d i n a l l y - d e t e r m i n e d p o i n t scales t o assess severity o f c o n d i t i o n s . The M o d i f i e d C r i c h t o n R o y a l behavioural r a t i n g scale is often used i n this regard ( W i l k i n and J o l l e y , 1979). A criticism o f this approach is that i t assumes that abilities and incapacities are n o t o n l y cumulative b u t additive as w e l l . Neither can cardinal scales guarantee homogeneity o f depen­ dency across scale p o i n t s because various combinations o f disabilities can y i e l d the same score. There is no d o u b t that w i t h i n the objectives o f par­ ticular studies the aggregation o f p o i n t scales can provide useful i n f o r m a t i o n . However, they are n o t a s o l u t i o n t o the problems o f c o m b i n i n g scales even i f they sometimes prove a convenient way o f m a k i n g q u i c k progress.

Some analysts have taken an even more practical approach t o measuring dependency i n elderly persons. T h e y seek and accept the assessment o f the health professionals charged w i t h the de facto responsibility o f placement decision-making for elderly persons. M o o n e y ( 1 9 7 8 ) , for example, d i d n o t a t t e m p t t o i d e n t i f y fine or scaleable degrees o f differences i n dependency among elderly clients i n c o m m u n i t y , residential and hospital care. Instead he used criteria w h i c h the nursing staff, caring for the elderly under observation, used daily t o characterise risk or dependency among their clients. Judgements

on placement and o n whether elderly were o n / n o t o n the margin o f care between d o m i c i l i a r y and residential h o m e ; d o m i c i l i a r y and hospital; and resi­ dential home and hospital, were made by matrons and p u b l i c health nurses. The characteristics o f the elderly considered i m p o r t a n t i n this approach were as f o l l o w s : age, living alone, acute illness i n the last m o n t h , i n c o n t i n e n t , i n s t a b i l i t y (frequent falls), night confusion, m e n t a l i m p a i r m e n t , self neglect, tendency t o isolation, i n a b i l i t y for self-care; and unable alone t o : get o u t o f bed, move around the house, c l i m b stairs or move o u t o f doors.

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The above approach yielded 64 d o m i c i l i a r y based elderly on the margin o f i n s t i t u t i o n a l care and 80 i n s t i t u t i o n a l based elderly o n the margin o f d o m i ­ ciliary care. The r a t i n g scheme used b y the c o m m u n i t y physician reflected the medical and psycho-social c o n d i t i o n o f the elderly-person as w e l l as their physical abilities and capacity t o complete activities o f daily living. Given the subjective nature o f the selection procedure, and faced w i t h the r e a l i t y that selected~^lderly persons were c u r r e n t l y being cared for w i t h i n particular regimes, those elderly chosen for inclusion i n the study were asked t o o r d i n a l l y self-rank their health status across a number o f dimensions.

As m i g h t be expected, homogeneity o f dependency, along a n u m b e r o f dimensions, was evident between the t w o groups (Table 1). However, significant differences between the t w o groups occurred o n the f o l l o w i n g dimensions: m o b i l i t y outside, a b i l i t y t o negotiate stairs and steps, meal preparation, house cleaning, bathing all over, l a u n d r y , shopping and refuse disposal. A priori, one m i g h t expect that i f there is to be heterogeneity between groups the d o m i c i l i a r y group w o u l d be less incapacitated on all significant dimensions. This is n o t the case. The d o m i c i l i a r y group is less incapacitated on o n l y t w o dimensions: the a b i l i t y t o bathe all over and m o b i l i t y outside the home.

T a b l e 1: Mean Rank Dependency Scores Using Mann Whitney U-Test:

A Comparison of Domiciliary and Institutionally Based Elderly

Variable Ins.

(n = 80)

Dom. (n = 64)

M-W U Statistic

C o n t i n e n c e 6 9 . 6 5 7 6 . 0 6 2 3 3 2 . 0 M e n t a l state 7 3 . 7 0 7 1 . 0 0 2 4 6 4 . 0 M o b i l e i n b u i l d i n g 7 2 . 1 0 7 3 . 0 0 2 5 3 8 . 0 W a s h hands a n d face 7 2 . 5 0 7 2 . 5 0 2 5 6 0 . 0 Dress ' 7 2 . 9 0 7 2 . 0 0 2 5 2 8 . 0 See 7 1 . 5 0 7 3 . 7 5 2 4 8 0 . 0 H e a r 7 1 . 5 0 7 3 . 7 5 2 4 8 0 . 0 S p e a k 7 2 . 0 0 7 3 . 1 3 2 5 2 0 . 0 S i t / s t a n d steady 7 3 . 7 0 7 1 . 0 0 2 4 6 4 . 0 *Mobile outside 9 0 . 8 8 5 7 . 8 0 1 3 8 4 . 0 * S t a i r s a n d steps 6 1 . 6 0 8 6 . 1 3 1 6 8 8 . 0 *Prepare meals 5 9 . 1 0 8 9 . 2 5 1 4 8 8 . 0 * H o u s e c l e a n 6 1 . 6 0 8 6 . 1 3 1 6 8 8 . 0 * B a t h all over 9 1 . 3 0 5 7 . 6 0 1 3 6 8 . 0 * L a u n d r y 5 9 . 9 0 8 8 . 2 5 1 5 5 2 . 0 *S h o p p i n g 5 9 . 0 0 8 9 . 3 8 1 4 8 0 . 0 * R e f u s e disposal 5 9 . 8 0 8 8 . 3 8 1 5 4 4 . 0

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The lower self-ranking b y the i n s t i t u t i o n a l group on all o f the other signifi­ cant dimensions deserves explanation. I t may reflect M i l l e r s ' ( 1 9 8 4 ) suggestion that instead o f patient dependency causing nursing action, the latter can cause patients t o become more or less dependent i n a non-systematic manner. L o w e r self-ranking b y the i n s t i t u t i o n a l group may also reflect the fact that the latter are n o t often asked or p u t i n a position t o test their abilities along certain dimensions — hence their more positive self-assessment on these dimen­ sions may reflect a t i m e when such tasks c o u l d be accomplished. T e m p o r a l differences i n placement p o l i c y for elderly persons may also be a c o n t r i b u t o r y factor i n explaining l o w e r rankings by i n s t i t u t i o n a l patients. Because o f resource constraints d o m i c i l i a r y elderly have nowadays t o score more h i g h l y on some dependency ratings before they w i l l be a d m i t t e d t o i n s t i t u t i o n s because o f this dependency.

I l l D I S C R I M I N A N T F U N C T I O N

The absence o f homogeneity on all dimensions o f dependency and the de

facto observed placement o f elderly persons makes i t w o r t h w h i l e investigating

further differences between the d o m i c i l i a r y and i n s t i t u t i o n a l groups. One possibility i n this regard is t o estimate a discriminant f u n c t i o n that w o u l d allow the i d e n t i f i c a t i o n o f a simultaneous set o f variables useful i n analysing the difference between groups o f elderly persons. M o o n e y ( 1 9 7 8 ) , for example, estimated a discriminant f u n c t i o n for elderly, w i t h i n a balance o f care m o d e l , and f o u n d that a f u n c t i o n w i t h four variables: living alone, age, stairs w i t h i n dwellings and m o b i l i t y had a high a b i l i t y t o p r e d i c t those elderly on the mar­ gins o f alternative regimes o f care.

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b u t subject t o significant bias i n many cases. I n the l i g h t o f the d i c h o t o m o u s nature o f m a n y o f Mooney's (1978) variables the reader is encouraged t o treat his discriminant results i n the same manner.

I n order t o estimate the discriminant f u n c t i o n a stepwise o p t i o n was used t o select the p r i m e d i s c r i m i n a t i n g variables f r o m among the appropriate n u m b e r o f variables available for inclusion i n the stepwise procedure. A t each step the variable t h a t results i n the smallest Wilks L a m b d a (the p r o p o r t i o n o f the t o t a l variance i n the discriminant scores n o t a t t r i b u t a b l e t o difference between groups) for the discriminant f u n c t i o n is selected for e n t r y (Norusis, 1985). The number o f steps was l i m i t e d t o eight i n the interest o f m a i n t a i n i n g a fair case variable r a t i o . The discriminant score evaluated at group means is 1.05 for the c o m m u n i t y group and - 0 . 8 4 0 for the i n s t i t u t i o n a l group. The coefficient o n each variable shows that variable's relative c o n t r i b u t i o n t o the overall discriminant f u n c t i o n and the value o f the coefficient for a particular variable depends on the other variables i n c l u d e d i n the f u n c t i o n . The actual signs o f the coefficients are a r b i t r a r y . The positive coefficients for the variables a b i l i t y t o bathe, m o b i l i t y outside, living w i t h others and living c o n d i t i o n s c o u l d j u s t as w e l l be negative i f the signs o f the other coefficients were reversed.

T a b l e 2: Standardised Discriminant Function Coefficients

Correlations between discriminating

Variables Coefficients variables and canonical

discriminating functions

A b i l i t y to b a t h e (all over) 0 . 5 1 3 0 . 6 0 4 M o b i l i t y outside the h o m e 0 . 5 4 3 0 . 5 7 4 H o m e h e l p - 0 . 4 4 4 - 0 . 4 7 7 G e n e r a l p r a c t i t i o n e r - 0 . 2 7 3 - 0 . 2 5 3 L i v i n g w i t h others 0 . 2 2 0 0 . 0 2 6 P u b l i c h e a l t h nurse - 0 . 2 1 9 - 0 . 2 9 2 S e x of elderly p e r s o n - 0 . 2 2 8 - 0 . 0 3 0 L i v i n g c o n d i t i o n s 0 . 1 7 7 0 . 1 1 7

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I n terms o f the accuracy o f p r e d i c t i o n o f d o m i c i l i a r y and i n s t i t u t i o n a l elderly, using these eight factors, the overall p r e d i c t i o n rate is 84.0 per cent; 78.1 per cent o f d o m i c i l i a r y elderly are c o r r e c t l y classified; 88.8 per cent o f

i n s t i t u t i o n a l i s e d elderly are c o r r e c t l y classified. A n y satisfaction regarding

the good classificatory performance must however be tempered b y the caveats raised above. F u r t h e r m o r e , the use o f a stepwise selection procedure invalidates tests o f significance (Draper and S m i t h , 1966) w h i c h consequently are n o t always reliable ( K e n n e d y , 1985).

One way to overcome the problems posed b y the d i c h o t o m o u s nature o f many o f the variables used i n the analysis is t o use an o r d i n a r y b i n o m i a l l o g i t procedure. A m u l t i v a r i a t e m o d e l has, therefore, been estimated for the data and the results o f the l o g i t regression are presented i n Table 3. M a n y variables were considered b u t o n l y those variables t h a t were significant and/or f o r m e d part o f the discriminant f u n c t i o n estimated i n Table 2 are shown.

For the l o g i t m o d e l a linear f u n c t i o n o f the independent variables is equal t o the l o g a r i t h m o f the r a t i o o f the p r o b a b i l i t y o f an elderly person being cared for at home i n the c o m m u n i t y and being cared for w i t h i n the l o n g stay geriatric i n s t i t u t i o n .

T h e p r o b a b i l i t y o f being i n the c o m m u n i t y is equal t o :

where X/3 is a linear f u n c t i o n o f the characteristics o f elderly persons. This i n t u r n implies t h a t the p r o b a b i l i t y of being i n the i n s t i t u t i o n is equal t o

I V L O G I T M O D E L

Prob (Coram) =

ex|3

1 + ex0

Prob (Inst) = 1 - Prob ( C o m m ) = 1

This implies that

Prob ( C o m m ) _ X|3

Prob (Inst)

So t h a t :

I n

Prob ( C o m m )

Prob (Inst)

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the c o m m u n i t y and 0 i f the elderly person is i n the l o n g stay geriatric insti­ t u t i o n . O n l y the final version o f the explanatory variables are presented here. Therefore the variables discussed below either achieve desired significance levels or f o r m p a r t o f the discriminant f u n c t i o n estimated above.

(a) Sex

I f an elderly person is classified as female, she is given a score o f 1; males are classified as 0. Given that females live longer than males and that ageing and hospitalisation are h i g h l y correlated i t is expected that the sign on this coefficient w i l l be negative.

(b) Living Alone

This variable assumes the value of 1 i f an elderly person lives alone. The a b i l i t y o f an elderly person t o live i n the c o m m u n i t y is enhanced i f the elderly person lives w i t h others or has a n e t w o r k o f f a m i l y and friends w h o provide care and c o m m u n i c a t i o n : M o o n e y ( 1 9 7 8 ) , Wright, etal. ( 1 9 8 1 ) . Consequently, the expected sign on this coefficient w i l l be negative.

(c) Living Conditions

We are interested here i n estimating the extent t o w h i c h good l i v i n g condi­ tions influences the p r o b a b i l i t y o f being cared for at home i n the c o m m u n i t y . The d o m i c i l i a r y group have significantly better household amenities t h a n the i n s t i t u t i o n a l group had p r i o r t o i n s t i t u t i o n a l i s a t i o n . F u r t h e r m o r e , 48 per cent o f the d o m i c i l i a r y group described their l i v i n g conditions as good w h i l e o n l y 30 per cent o f the i n s t i t u t i o n a l group described their former living con­ ditions as good. I t is expected that good l i v i n g conditions w i l l be reflected b y an increase i n the l i k e l i h o o d o f an elderly person being cared for at home.

(d) General Practitioner, Public Health Nurse, Home Help

These variables measure the availability and take up o f the s t a t u t o r y ser­ vices. Some evidence exists w h i c h suggests that some applicants for residential care c o u l d be m a i n t a i n e d at home w i t h a guaranteed delivery o f f o r m a l inten­ sive d o m i c i l i a r y care ( A v o n C o u n t y Council Social Services Department,

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Davies, 1980). I n the l i g h t of this evidence and experiment the coefficients on each o f the above variables are expected t o be positive.

(e) Inability to Bathe All Over; Immobility Outside the House

Given the results o f the M a n n W h i t n e y U Test and the discriminant approxi­ mations the coefficients on b o t h these variables are expected t o be negative. The i m m o b i l i t y variable finds particular support i n the literature as being i m p o r t a n t i n decisions t o transfer elderly f r o m d o m i c i l i a r y t o i n s t i t u t i o n a l care (Wright, et al, 1 9 8 1 ; M o o n e y , 1978). B o t h variables are nearly always i n c l u d e d i n indices used for the assessment o f whether elderly persons are m o r e suitable for d o m i c i l i a r y care or i n s t i t u t i o n a l care ( K y l e , et al., 1987; Gibbins, et al., 1982).

(f) Other Variables

Other variables were estimated. A l l significant dimensions o f dependency that had been i d e n t i f i e d using the M a n n W h i t n e y comparison o f mean rank scores were considered (recoded t o read 1 for unable and 0 for able) i n vari­ ous estimations o f the l o g i t f u n c t i o n . O n l y bathing and m o b i l i t y were signifi­ cant. Age was also i n c l u d e d i n the m o d e l , dichotomised i n t o those greater than 65 and less than 75 equal t o 1, otherwise equal t o 0. Most surprisingly, given its i m p o r t a n c e i n other b o u n d a r y o f care models (Mooney, 1978), age t u r n e d o u t t o be c o r r e c t l y signed b u t insignificant. Perhaps a more sensitive disaggregation o f age w o u l d have p r o d u c e d a more significant effect. A l l non-significant variables d i d have the correct sign. For example, the variable i n a b i l i t y t o c l i m b stairs and steps had a positive sign, reflecting the earlier

discussion on w h y d o m i c i l i a r y elderly m a y have more disability o n this vari­ able than i n s t i t u t i o n a l patients.

I n f o r m a t i o n on i n f o r m a l care was n o t available for the institutionalised group and so c o u l d n o t be i n c l u d e d i n the logit expression. Neither was i t possible t o use i n f o r m a t i o n o n the p u r e l y medical c o n d i t i o n o f the elderly, either d o m i c i l i a r y or institutionally-based. The inclusion o f variables reflecting b o t h i n f o r m a l care and medical criteria w o u l d , u n d o u b t e d l y , have enhanced the m o d e l .

V T H E R E S U L T S

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i n t e r p r e t i n g measures o f association as quasi R , especially since the variables m a y be strongly related even t h o u g h the coefficients are small.

B o t h i m m o b i l i t y and i n a b i l i t y t o bathe are significant ( 1 % level) and cor­ r e c t l y signed. A n increase i n dependency o n b o t h these dimensions increases the l i k e l i h o o d that an i n d i v i d u a l is i n an i n s t i t u t i o n . Similarly, living alone decreases the l i k e l i h o o d o f l i v i n g at home. However, this variable d i d n o t reach conventional levels o f significance even t h o u g h i t is signed c o r r e c t l y . Being female also enters negatively b u t insignificant on the l i k e l i h o o d o f an elderly person l i v i n g at home i n the c o m m u n i t y . The higher p r o b a b i l i t y o f females being i n i n s t i t u t i o n a l care more than l i k e l y reflects their l o n g e v i t y than any other factor. G o o d l i v i n g conditions are, however, significant (5% level) and c o r r e c t l y signed. The l i k e l i h o o d o f an elderly person living at home i n the c o m m u n i t y increases as their l i v i n g c o n d i t i o n s i m p r o v e . Given that social factors influence most placement decisions, i t is h a r d l y surprising that good housing stock has a role t o p l a y i n p r o l o n g i n g the c o m m u n i t y life of an elderly person.

A l l o f the s t a t u t o r y services i n c l u d e d i n the m o d e l are c o r r e c t l y signed. However, o n l y the variables general p r a c t i t i o n e r (5% level) and home help ( 1 % level) are significant for these data. The absence o f significance o n the p u b l i c health nurse variable more than l i k e l y reflects the comprehensive nature o f this service for at risk elderly persons. A l m o s t all elderly persons received visits f r o m the p u b l i c health nurse, c u r r e n t l y i n the case o f the d o m i c i l i a r y group and f o r m e r l y i n the case o f the i n s t i t u t i o n a l group. The availability o f h o m e help services significantly increases the l i k e l i h o o d o f d o m i c i l i a r y care. H o m e helps provide m a n y basic services that w o u l d , otherwise, be denied the elderly person due t o their incapacity to carry o u t such activities. H o m e help is p a r t i c u l a r l y beneficial i f the elderly person does n o t have a n e t w o r k o f family and friends t o provide help w i t h these activities.

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T a b l e 3: Logit Analysis of Placement of Elderly Persons

Variable Coefficient SE t

S e x of elderly p e r s o n - 0 . 1 4 7 0 . 1 3 3 - 1 . 1 0 3 L i v i n g alone - 0 . 1 5 7 0.141 - 1 . 1 1 7 P u b l i c h e a l t h nurse 0 . 2 1 6 0 . 2 1 2 1.016 G e n e r a l p r a c t i t i o n e r 0 . 8 0 6 0 . 3 1 3 + 2 . 5 8 0 * H o m e help 0.707 0 . 2 2 3 + 3 . 1 7 1 * * I m m o b i l i t y outside the h o m e - 0 . 5 1 7 0 . 1 4 3 - 3 . 6 1 0 * * U n a b l e to b a t h e (all over) - 0 . 5 4 4 0 . 1 5 0 - 3 . 6 2 0 * * L i v i n g c o n d i t i o n s 0 . 3 2 4 0 . 1 3 8 2 . 3 5 3 *

Analysis of Dispersion

Dispersion

Entropy Concentration DF

S o u r c e o f v a r i a t i o n 4 4 . 7 2 9 3 6 . 7 7 8 D u e to residual 5 4 . 2 4 3 3 4 . 3 8 2

T o t a l 9 8 . 9 7 2 7 1 . 1 6 0 143

Measures of Association

E n t r o p h y = . 4 5 1 9 3 5 C o n c e n t r a t i o n = . 5 1 6 8 3 3

Goodness of Fit Statistics

L i k e l i h o o d R a t i o C h i S q u a r e = 4 3 . 4 3 9 6 0 D F = 5 3

P = . 8 2 3 P e a r s o n C h i S q u a r e = 4 3 . 1 6 5 0 0

D F = 5 3 P = . 8 3 0

• S i g n i f i c a n t at the level of 5 per cent. • • S i g n i f i c a n t at the level of 1 per cent.

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i n f o r m a l care and pure medical care). The size o f the elderly groups under observation and the geographical restrictiveness o f the site chosen for study should also cause some concern. However, the l o g i t m o d e l is a p r o m i s i n g m e t h o d o l o g y for further w o r k i n this area.

V I T H E COST O F C A R E

Formal Care

I n f o r m a t i o n was o n l y collected on the actual, de facto, use o f f o r m a l care b y the d o m i c i l i a r y group deemed t o be o n the margin o f i n s t i t u t i o n a l care. A l m o s t all members o f this group receive visits f r o m the general p r a c t i t i o n e r and the public health nurse. A b o u t one-third receive visits f r o m the home help services while o n l y 14 per cent receive the service o f meals o n wheels. A l t h o u g h visits f r o m the occupational therapist and the c h i r o p o d i s t do n o t , i n general, occur, facilities are available i n cases where an acute need has been i d e n t i f i e d ; 18.8 per cent o f the group travel t o the c h i r o p o d i s t . The data used t o cost these services are based o n prevailing 1987 p a y m e n t rates for visits and salary levels, whichever is appropriate t o use for the p a r t i c u l a r service. Travel costs are calculated at current p u b l i c sector rates, adjusted t o give an average cost per m i l e .

Respite care i n the district geriatric i n s t i t u t i o n is availed o f b y 37.5 p e r c e n t of the d o m i c i l i a r y g r o u p ; a t o t a l o f 70 weeks d u r i n g the last year was spent i n respite care. The current and capital costs o f this care must be i n c l u d e d i n the d o m i c i l i a r y care costings. A n estimate o f the costs o f attendance at the hospital day c e n t r e2 must also be i n c l u d e d ; a t o t a l o f 48 visits per week

is made b y the 3 4 . 1 per cent o f the d o m i c i l i a r y group w h o attend. There is no readily available i n f o r m a t i o n on the cost o f this t y p e o f hospital day care. For the purposes o f this study a rather crude and unsatisfactory estimate o f cost is made, based o n w h a t is c u r r e n t l y k n o w n about the cost per attendance at day hospital care i n the N a t i o n a l H e a l t h Service ( H i l d i c k - S m i t h , 1984) and the cost o f a t t e n d i n g day care centres i n the Eastern H e a l t h Board ( N a t i o n a l Council for the Aged, 1987).

The t o t a l cost o f d o m i c i l i a r y group modifications t o housing stock, specifi­ cally t o i m p r o v e caring facilities w i t h i n the household, a m o u n t e d t o £ 2 4 , 0 0 0 . Assuming a life-span o f 10 years and discounting at 5 per cent ( b o t h can be subjected t o sensitivity analysis), the household a l t e r a t i o n cost a t t r i b u t a b l e t o each d o m i c i l i a r y elderly person can be estimated. O n l y 20 per cent o f the

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elderly households, however, made alterations t o their dwellings, spending between £ 5 0 0 and £ 4 , 0 0 0 o n m o d i f i c a t i o n s .

I n f o r m a t i o n was also collected o n the availability and rate o f religious and v o l u n t a r y visiting t o the d o m i c i l i a r y elderly g r o u p ; 6 5 . 0 per cent o f the group received religious visits; 23.0 per cent o f the group received visits f r o m volun­ tary organisations. B o t h types o f visits are tentatively valued at the h o u r l y home help rate o f £ 2 . 0 0 per hour. The use o f this valuation for religious visits is n o t inconsistent w i t h available i n f o r m a t i o n on the de facto fee per i t e m o f service being offered t o religious for services rendered.

The cost o f pharmaceutical c o n s u m p t i o n b y the d o m i c i l i a r y group is n o t included i n this study. The c o l l e c t i o n o f this i n f o r m a t i o n proved b e y o n d the scope o f the study. Neither is the cost o f in-patient acute care, required b y the d o m i c i l i a r y group d u r i n g the past year, i n c l u d e d i n the analysis. A l t h o u g h a t o t a l o f 60 weeks was spent i n acute care the marginal cost i n f o r m a t i o n necessary t o c o m p u t e the m o n e t a r y valuation o f this care is n o t available.

The cost o f formal s t a t u t o r y service provision for the d o m i c i l i a r y group is shown i n Table 4. The estimated average weekly d o m i c i l i a r y cost o f care per elderly person is £ 3 0 . 7 0 . This cost is sensitive t o all variables shown i n the table b u t is p a r t i c u l a r l y so t o the estimated m o n e t a r y valuation o f hospital day care. I t is u n f o r t u n a t e that comprehensive and accurate cost i n f o r m a t i o n is n o t avail­ able for this variable given the heterogenous nature o f care possible w i t h i n

this f o r m o f care. M o r e generally the conventional w i s d o m that day hospital care represents the future d i r e c t i o n o f care o f the elderly in this c o u n t r y , makes the c o n t i n u e d absence o f cost i n f o r m a t i o n on this service p a r t i c u l a r l y alarming. The absence o f i n f o r m a t i o n o n drugs and acute care costs is also regretted. The m o s t recent available estimate o f the weekly average cost o f keeping a p a t i e n t i n the nearest acute care hospital t o the d o m i c i l i a r y group is £655.43 (Department o f Health, 1985). There may, however, be a significant difference between the marginal and average cost o f acute care b y client and diagnostic group. Hence average cost is n o t suitable as a basis for acute care costing i n this m o d e l . I f the u t i l i s a t i o n o f acute care facilities and the consump­ t i o n o f drugs c o u l d be assumed n o t t o differ significantly between marginal d o m i c i l i a r y and marginal i n s t i t u t i o n a l elderly the absence o f cost i n f o r m a t i o n m a y n o t be so damaging, especially i n models that seek o n l y t o examine relative cost effectiveness between regimes. Nevertheless, their absence f r o m this study serves t o underestimate the real cost o f d o m i c i l i a r y care.

I t must be borne i n m i n d that the level o f f o r m a l care services examined is

de facto care for the group under observation. There is no i m p l i c a t i o n i n the

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T a b l e 4: Cost of Statutory Services

Service Uptake

%

Cost per patient per week £

V i s i t s b y G P 9 8 . 4 1.05 V i s i t s to the G P 4 3 . 8 0.19 T r a v e l costs 4 3 . 8 0 . 0 4 V i s i t s b y the P H N 9 6 . 9 0 . 5 4 T r a v e l costs 9 6 . 9 0.04 V i s i t s b y h o m e help 32.8 7.09 Meals on w h e e l s 14.1 1.16 Religious visits 65.6 0.07 V o l u n t a r y visits 2 3 . 4 0.03 V i s i t s to c h i r o p o d i s t 18.8 0.04 A l t e r a t i o n s to dwelling 2 0 . 3 0.93 R e s p i t e care ( c u r r e n t ) 37.5 4.01 R e s p i t e care (capital) 1.03 T r a v e l to d a y care 0.02 H o s p i t a l day care

(current a n d capital) (est.) 34.1 1 4 . 4 6 3 0 . 7 0

the expansion o f specific c o m m u n i t y care services, may, perhaps, o n l y be feasible i f resources are redeployed f r o m the i n s t i t u t i o n a l sector. Closing i n s t i t u t i o n s is n o t a simple task and takes a l o n g t i m e t o complete. I n the meantime physicians m a y be u n w i l l i n g t o dispatch elderly i n t o the c o m m u n i t y because the necessary and sufficient services are n o t available t o provide o p t i m a l care.

V I I I N F O R M A L C A R E

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The practicalities o f valuing i n f o r m a l care have led m a n y t o the view that, i n the absence o f u n p a i d resident carers, society w o u l d have t o pay the market rate for care o f the elderly person (Wright, 1987). This approach is i m p l i c i t l y accepted i n this paper. However, the relevant o p p o r t u n i t y costs for carers m a y n o t o n l y be m a r k e t w o r k - t i m e forgone. Therefore this analysis includes details o f u n p a i d non-market w o r k forgone and leisure time forgone b y carers o f the elderly persons. Carers give up paid w o r k (7.8%), u n p a i d w o r k (76.6%) and leisure t i m e (84.4%) t o l o o k after the elderly group. Hours o f p a i d w o r k forgone is valued at the average industrial earnings h o u r l y rate for 1987 (£4.68 per h o u r ) ; non-market u n p a i d w o r k is valued at the h o u r l y home help rate (£2.00 per h o u r ) ; leisure t i m e forgone is valued, f o l l o w i n g the literature on transport appraisal ( L e i t c h , 1 9 7 8 ) , at 25 per cent o f w o r k i n g t i m e (£1.17 per h o u r ) . Sensitivity analysis can and should be applied t o these assumptions especially where base line valuations are crucial and significant i n determining final outcomes.

The a m o u n t o f i n f o r m a l care expended o n the d o m i c i l i a r y group is dis­ aggregated b y caring a c t i v i t y and s h o w n i n Table 5. N o t all elderly i n the d o m i c i l i a r y group receive i n f o r m a l care services and some services are pro­ vided m o r e than others. A l m o s t 78 per cent o f the d o m i c i l i a r y elderly group receive some supervision; 77 per cent receive m o b i l i t y assistance; 69 per cent receive l a u n d r y services; while 75 per cent had carers w h o p r o v i d e d help w i t h shopping. A t the other extreme o n l y 1 elderly person requires help w i t h feed­ i n g ; 19 per cent require help w i t h general a d m i n i s t r a t i o n ; while 36 per cent require help w i t h b a t h i n g . The aggregate number o f i n f o r m a l care hours per day received b y the d o m i c i l i a r y group is 515 hours; supervision constitutes 48 per cent o f all caring hours; m o b i l i t y assistance (21%) and c o o k i n g (15%) are n e x t i n order o f t i m e allocation. N o a t t e m p t is made t o disaggregate care by dependency category or t o weight activities b y the unpleasantness o f the tasks t o be done. The average a m o u n t o f caring hours given t o those elderly receiving care is 10.30 hours per day; for all elderly (whether receiving care or n o t ) the average caring hours per day is 8.05 hours. The i n f o r m a t i o n o n standard deviation c o n t a i n e d i n Table 5 shows that there is considerable v a r i a t i o n i n hours o f care per i t e m o f service, especially w i t h regard t o shopping, l a u n d r y and general a d m i n i s t r a t i o n .

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T a b l e 5: Informal Domiciliary Care Hours Per Day

No. of

community Hours of paid

Hours of

unpaid (non- Hours of leisure time forgone by

carers

Total hours of Mean hours of Standard deviation Service elderly

receiving (n = 64)

work given up by carers

market) work given up by

carers

Hours of leisure time forgone by

carers

care to those receiving

care to those receiving

hours of care to receiving

S u p e r v i s i o n 50 1 9 . 0 0 1 3 0 . 5 0 9 9 . 0 0 2 4 8 . 5 0 4 . 9 7 2 . 7 0

B a t h i n g 2 3 0 . 2 6 1.20 3 . 6 4 5 . 1 0 0.22 0.21

>

T o i l e t i n g 0 0 . 0 0 0 . 0 0 0 . 0 0 0 . 0 0 0 . 0 0 0 . 0 0 o D r e s s i n g 29 2 . 0 0 8 . 7 9 2 0 . 1 0 3 0 . 8 9 1.07 0.90 H EC S h o p p i n g 4 8 0 . 1 4 9 . 9 7 8 . 3 4 18.45 0.38 0 . 3 9 W

W

C o o k i n g 45 2 . 5 0 5 8 . 3 0 1 4 . 9 0 7 5 . 7 0 1.68 0 . 8 0 C D w F e e d i n g 1 0 . 0 0 2 . 0 0 0 . 0 0 2 . 0 0 2 . 0 0

-

fa f

L a u n d r y 4 4 0 . 8 0 1 1 . 1 7 6 . 1 5 1 8 . 1 2 0.41 0.57 M o b i l i t y

assistance 4 9 6 . 5 0 5 6 . 6 5 4 7 . 1 5 1 1 0 . 3 0 2 . 2 5 1.24 G e n e r a l

a d m i n i s t r a t i o n 12 0 . 1 4 2 . 0 0 2 . 6 6 4 . 8 0 0 . 4 0 0 . 8 2 O t h e r 4 0 . 1 4 0 . 0 0 0 . 9 4 1.08 0.27 0 . 1 5

A l l 50 3 1 . 5 0 2 8 0 . 5 8 2 0 2 . 8 8 5 1 4 . 9 4 1 0 . 3 0 4 . 3 8

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Sensitivity analysis can and should be applied to variables whose valuation is far f r o m settled and w h i c h are l i k e l y t o affect the outcome o f the analysis. I n f o r m a l care is the most problematic and crucial variable. I t is, therefore, w o r t h w h i l e t o briefly consider i f alternative valuations affect the o u t c o m e . I f i n f o r m a l care is n o t valued, the cost of c o m m u n i t y care for the d o m i c i l i a r y group is e n t i r e l y focused o n f o r m a l care (estimated t o be £30.70 per elderly person per week) and represents a comparatively cheap o p t i o n for care o f the elderly. A l t e r n a t i v e l y , i f the o p p o r t u n i t y cost o f non-market w o r k time for­ gone is valued, n o t at the h o u r l y h o m e help rate (£2.00 per h o u r ) , b u t at the average industrial wage rate (£4.64 per h o u r ) , the i n f o r m a l care cost per elderly person per week increases t o £ 1 8 5 . 6 2 . The latest available estimate o f the weekly cost t o a health board o f m a i n t a i n i n g an elderly person i n a l o n g stay geriatric hospital is £ 1 5 9 . 0 0 (National C o u n c i l for the Aged, 1988). Thus, i n this case, d o m i c i l i a r y care, o n l y taking i n t o account i n f o r m a l care, is more expensive than i n s t i t u t i o n a l care. When f o r m a l statutory c o m m u n i t y care ser­ vices are valued and i n c l u d e d the cost o f d o m i c i l i a r y care increases t o £ 2 1 6 . 3 2 . Clearly, the decision t o value i n f o r m a l care and the m e t h o d o l o g y used for such valuation does make a difference, especially i f the cost effectiveness o f d o m i c i l i a r y care is being compared t o that o f i n s t i t u t i o n a l care.

V I I I D I S C U S S I O N

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The discriminant f u n c t i o n estimated for the data i n this study is unreliable due t o the m u l t i v a r i a t e n o r m a l i t y assumption being breached on a n u m b e r o f variables. A n a p p l i c a t i o n o f the l o g i t procedure provides a m u c h more useful framework for the analysis o f crucial placement variables. I n particular, the f o l l o w i n g variables prove significant w h e n estimated using the l o g i t regression: i m m o b i l i t y outside the home, i n a b i l i t y t o bathe, use o f general p r a c t i t i o n e r services, use o f h o m e help services and c o n d i t i o n o f housing. A l l variables i n c l u d e d i n the l o g i t expression have the, a priori, expected sign.

The major factor i n d e t e r m i n i n g the real cost o f d o m i c i l i a r y care is the extent t o w h i c h i n f o r m a l care is valued i n m o n e t a r y terms. I n f o r m a l care w h e n valued along the base lines discussed is over three times above the estimated

de facto cost o f f o r m a l c o m m u n i t y care services. There are good reasons w h y

i n f o r m a l care should be valued — there are real o p p o r t u n i t y costs associated w i t h care. There is less agreement o n h o w i n f o r m a l care should be valued. The most practical approach has been t o use the v a l u a t i o n o f services that w o u l d have t o be p a i d for i n the event o f i n f o r m a l carers n o t being available. Such an approach m a y over-estimate the true o p p o r t u n i t y cost o f caring — many carers enjoy the caring role, often perceiving the role as aleisure t i m e a c t i v i t y . F u r t h e r m o r e n o t all caring involves m a r k e t w o r k - t i m e forgone — non-market w o r k t i m e and leisure t i m e may, instead, be forgone. There are strong argu­ ments, however, that, no matter w h a t the social and/or m o r a l responsibility felt b y carers, there is a diminishing marginal v a l u a t i o n o f t i m e spent caring. Real o p p o r t u n i t y costs do exist and are perceived b y carers.

There is n o i m p l i c a t i o n i n the study that the current placement o f elderly persons should be disturbed w i l l y n i l l y or that existing c o m m u n i t y care ser­ vices are o p t i m a l or even adequate for current numbers o f d o m i c i l i a r y elderly. F u r t h e r m o r e some o f the elderly m a y actually like where they are n o w living, whether this is i n d o m i c i l i a r y or i n s t i t u t i o n a l care. The relevance o f the analysis may be t o raise critical issues about the future placement o f elderly persons especially w i t h regard t o the i d e n t i f i c a t i o n o f the crucial variables that serve either t o increase the l i k e l i h o o d o f d o m i c i l i a r y care or its alternative. The e x t e n t t o w h i c h care i n the c o m m u n i t y is dependent o n the availability o f i n f o r m a l carers is also acknowledged.

The m o d e l discussed i n this paper is, however, m o r e suggestive t h a n defini­ tive; its m a i n f u n c t i o n is to make e x p l i c i t many o f the issues that up t o n o w have remained either i m p l i c i t or c o m p l e t e l y h i d d e n . M u c h m o r e i n f o r m a t i o n is required o n the full range o f costs and benefits o f b o t h d o m i c i l i a r y and i n s t i t u t i o n a l care before a more c o m p l e x m o d e l can be developed (Wright,

et al., 1 9 8 1 , 1986). The assumption o f homogeneity across regimes w i t h

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