This research is aimed at improving the outcomes of long-term care decision making (LTCDM) by increasing the influence of elders in the decision making process. When decisions are made about long term care (decisions such as nursing home placement or entry into assisted living), elders may have insufficient influence in part because of the chaotic and crisis-driven nature of LTCDM. Thus, decisions may be made which are not consistent with the elder's values or wishes. Based on the literature and our own preliminary studies, we believe that this is a result of the failure to take explicit account of the values of elders and to have those values (rather than the values of others such as family members or professionals) play a determining role in LTCDM. To address this problem, we have designed an intervention to elicit the expression of elders' values and their value-based preferences and to mediate differences of values and preferences among elders, family members, and involved health professionals. The intervention involves seven steps: (1) determine the participants involved in the decision, (2) review the circumstances surrounding the need for the long-term care decision, (3) clarify issues/identify problems (4) identify service alternatives, (5) elicit values in a structure of fashion, (6) assess service alternatives using these values. (7) agree on a care plan. Because geriatric care is increasingly provided in the managed care setting, we plan to conduct this pilot and the full clinical trial to follow in a managed care setting. The objective of this project is to test the feasibility of a full clinical trial by conducting a pilot of this intervention in one managed care organization (MCO) with a Medicare risk contract, using a second Medicare MCO as control. Pre- and post-intervention instruments will be administered to subjects in both the control and experimental arms. Data collection will run for eight months and involve a total of 48 elder/involved family members sets (24 sets in each arm, for a total of at least 96 persons) for the pilot. In the full clinical trial, the objective will be to measure two primary endpoints: increased recognition of elders' values-based assessments by others and increased implementation of elders' preferences in the experimental arm; and two secondary endpoints; the increased frequency of expression of values and of values-based assessments of alternatives by elders.
