This study estimates how informal care, paid formal care, and caregiver stress or burden relate to nursing home placement. Data came from the 1999 National Long Term Care Survey and were merged with administrative data. Results show that stress is a strong predictor of entry over follow-up periods of up to two years, and physical strain and financial hardship are important predictors of high levels of caregiver stress. The estimates indicate that reducing these stress factors would significantly reduce caregiver stress and, as a result, nursing home entry. We conclude that initiatives to reduce caregiver stress hold promise as a strategy to avoid or defer nursing home entry.
Informal, primarily unpaid, care provided by family and friends is universally recognized to be the foundation of the long-term care system for older Americans. More than 90% of chronically disabled elders who remain in community residence and receive help with basic activities of daily living get some help from informal caregivers, primarily their spouses or children; nearly two-thirds receive all of such help from informal caregivers (Spillman and Black 2005). Recent reports have attempted to quantify the importance of informal caregivers by focusing on valuing the total hours of care they provide (Gibson and Houser 2007), and on the out-of-pocket costs they incur (Wagner 2007). Such estimates help characterize the scope of caregiving activities, but have fairly diffuse links with specific long-term care policy aims. In this study, we focus on a central issue in current long-term care policy--the relationship between informal caregiving and nursing home entry--and examine how a high level of stress or burden from caregiving relates to the likelihood of potentially permanent placements.
A number of recent studies have examined the relationship between informal caregiving and the use of nursing homes among older people. These studies have found evidence that having family members who can serve as informal caregivers, actually receiving informal care, and the number of hours of informal care are associated with reduced nursing home entry (Charles and Sevak 2005; Lo Sasso and Johnson 2002; Van Houtven and Norton 2004; Waidmann and Thomas 2003). Other recent research indicates that various measures of stress or burden resulting from caring for elders with dementia predict nursing home entry (Gaugler et al. 2000; Gaugler et al. 2003, 2005; Brown, Potter, and Foster 1990).
In this study, we consider more broadly the role of caregiver stress in the nursing home entry decision. We focus on a nationally representative sample of people age 65 or older with chronic disabilities who are receiving care in the community, using data on those elders and their primary informal caregivers. Our data come from the 1999 National Long-Term Care Survey (NLTCS). The data are unique in including not only detailed information on care recipients, but also information from caregivers about their caregiving experience and administrative data that allow us to observe both nursing home entry and duration of nursing home use over follow-up periods of up to five years. We estimate a comprehensive model of how formal care, informal care, and the caregiver's perceived stress from caregiving relate to future nursing home placement, among people with chronic disability and an established caregiving arrangement in the community. Evidence from such a model can contribute to a better understanding of where policy may best be able to intervene to provide support and incentives for informal caregivers, and the potential impacts of increased public caregiving supports on nursing home placement.
Specifically, we address the following questions:
* Does a high level of primary caregiver stress predict nursing home entry?
* What factors are associated with high levels of caregiver stress?
* What are the potential impacts on nursing home entry of reducing overall caregiver stress and specific factors associated with caregiver stress? …