Medical care utilization patterns and perceived health needs of 251 ambulatory elderly participants at the Lenox Hill Senior Citizen Center and New York Hospital clinics are compared using data from an interview survey. Two-thirds of the elderly were generally satisfied with their health cam and opposed to a specialized geriatrics facility. Respondents expressed a need for more information about medical care, particularly services in emergency situations.
Health Care in a Selected Urban Elderly Population Utilization Patterns and Perceived Needs Marilyn Iris Auerbach, AMLS.2 David W. Gordon, PhD,3 Alice Ullmann, CSW,4 and Michael J. Weisel, CSW5 The New York Hospital, a large voluntary teaching hospital affiliated with Cornell University Medical College, is located on the upper East Side of Manhattan, one of the wealthiest urban areas in the country. The immediate service area of the hospital (59th to 96th Sts., East River to Fifth Ave.) has a population of approximately 200,000, a large array of medical institutions, and a high ratio of physicians per 100,000 population. However, this area also has a higher than average proportion of elderly —17% are age 65 and older, compared with a city-wide average of 14%.
Many of these elderly have low incomes (15% of the area's 34,000 elderly residents are below the Federally designated poverty level) and, more often than not, live in tenements adjacent to new, luxury high-rise apartment buildings. Background of the Study
Large medical institutions similar to the New York Hospital-Cornell Medical Center serve the needs of patients throughout the city and surrounding region by providing specialized and advanced medical treatment. Since these institutions cannot survive within a vacuum, it is especially worthwhile to be responsive to particular needs, such as those ex'This study was supported in part by a grant from the New York Metropolitan Regional Medical Program. 'Assistant in Research, Dept. of Public Health, Room A-631, Cornell Univ. Medical College, 1300 York Ave., New York 10021. 'Research Associate. 'Assistant Professor of Social Work. 'Community Social Worker.
Vol.17, No. 4, 1977
pressed by members of community boards and representatives of committees, insofar as they relate to matters of health. At a number of meetings devoted to discussions of the role of the medical center, it was suggested that ambulatory health care for the elderly was deficient and that the health care that was provided lacked continuity. It was stated that many homebound elderly were unable to get physicians to make home visits, that both homebound and ambulatory elderly were concerned and confused about their coverage under Medicare and Medicaid, and that those who did find their way to the hospital were often sent from one clinic to another and were thus "lost in the shuffle." A:; Cantor and Mayer (1976) cogently observed,
On the face of it, older New Yorkers would seem to have ample resources to meet their considerable health needs. But for many residents of the city, particularly those who are old and poor, the system's magnitude and complexity make it confusing, insensitive, forbidding and often impenetrable.
The hospital and community representatives agreed that many of the health needs of the elderly poor were not being optimally met, but there was disagreement on the mode of delivery. In particular, local representatives suggested the establishment of a comprehensive geriatric health facility within the existing ambulatory care service of the hospital. Given the lack of empirical data about
341
the patients' desire for a special geriatric clinic, representatives of the medical center conducted a study in order to identify and compare the perceived health care needs and medical care utilization patterns of two selected groups—those participating in a senior citizen center and those involved in a hospital-based clinic. Description of the Setting and Assessment
The interviews were conducted at two locations: (1) The Lenox Hill Senior Citizen Center, sponsored by the Lenox Hill Neighborhood Association, which provides a wide range of services and programs for the elderly, including a Title XX hot lunch program. The Senior Citizen Center is located two blocks from The New York Hospital; (2) The New York Hospital's Ambulatory Services (out-patient department), which provides a complete range of medical and ancillary services for approximately 220,000 patient-visits per year. The Lenox Hill group (LH) consisted of elderly residents participating in social activities, while those in the New York Hospital group (NYH) consisted of elderly ambulatory patients. A certified social worker or supervised, trained volunteers conducted 251 interviews of persons who were 60 years of age and older and resided within the service area of the hospital. At the New York Hospital, interviewers selected 151 patients who were registered with the clinic clerk and seen by physicians in the General Medical Clinic or other clinics. At the Lenox Hill location, 100 respondents were chosen from those participating in the Title XX program or infrequent walk-in patrons. With respect to these settings, it should be kept in mind that we expected that the LH group would be in better health than the NYH group. The precoded questionnaire was the same for each group, with the exception of four questions specific to health care delivery at the New York Hospital, which were applicable to the NYH sample. Respondent information was obtained through a guided but flexible interview technique which utilized closed and open-ended questions, some adapted from earlier studies (Cantor & Mayer, 1974; Maddox, 1964; Townsend, 1963; Univ. of Rochester, 1968). The questionnaire was designed to provide general demographic information, as well as specific data concerning
health status, access to medical care, medical care utilization, continuity of care, financing of medical care, and satisfaction with health care. Living Arrangements Since we expected that the residential migration of the elderly population had been negligible, we inquired about the length of time each respondent had lived in his present apartment. The data revealed long-term residential stability for both groups —82% of the total sample had been living in the same apartment for 6 years or longer, and 6 1 % for Table 1. Selected Demographic Characteristics According to Croup: Percentage Distribution.
Demographic Characteristics Age Range: Mean: 60-74 75 + Sex Male Female Race White Black Hispanic Other Housing Apartment No. years in present apartment Under 10 11-20
20 + Elevatoror 1st floor 2-3 flight walk-up 3+ flight walk-up Occupation Blue collar White collar Housewife Income - Current Source Social Security SSI Other Currently employed Income - Perceived Sufficiency Comfortable Just enough Not enough
342
Interview Location New York Lenox Hill Hospital Ambulatory Neighborhood Services Association (N = 151) (N = 100)
60-91 years 72.9 years 55% 45
60-94 years 72.1 years 65% 35
37.1 62.9
30.0 70.0
94.0 3.3 2.0 0.7
98.0 — — 2.0
98.7
91.0
41.7 21.9 36.4 43.3 42.0 14.7
34.0 24.0 42.0 30.0 49.0 21.0
65.0 20.0 15.0
58.0 33.0 9.0
49.7 32.5 17.8 12.6
74.0 9.0 17.0 12.0
21.0 61.0 18.0
17.0 73.0 10.0
The Gerontologist
more than 10 years. As shown in Table 1, 30% had been residing in the same place for 30 years or more. Only 11 persons (4.4%) resided in rooms instead of apartments. Slightly more than one-half (57%) lived alone, 27% lived with their spouses, 8% with a sibling or friend, and 6% with their children. Since we were studying an elderly ambulatory population, it was of interest to discover that approximately 45% of the total sample had to walk two or more flights to reach their apartments; 17% occupied walk-ups of three or more flights. Although 7 1 % expressed satisfaction with their living arrangements, 18% who indicated dissatisfaction were usually those elderly living alone and reporting insufficient income. Of particular interest is the finding that one-quarter of those living in the same dwelling for over 30 years were dissatisfied with their living conditions. Dissatisfaction with living arrangements also increased in relationship to the number of flights an elderly person had to walk to reach his apartment. Most of the respondents indicated that they spent more than one-half of their income for rent and the lack of extra dollars kept them from moving from the upper floors of deteriorating buildings to those better maintained buildings with elevators and higher rents. Faced with the prospect of either remaining in unsatisfactory housing or moving to a strange neighborhood away from friends and acquaintances, known streets and shops, most of these elderly seemingly chose to live with the familiar. The lack of adequate income also seemed to have special relevance for the NYH group, since those who reported low income also reported worse health —a pattern found in other studies in recent years (Cantor & Mayer 1976; Tissue, 1972). Fifty percent of the NYH sample received their income from Social Security; additionally, 33% was eligible for and received funds through Supplementary Security Income (SSI). The data for the LH group revealed that, while 74% mentioned that they were receiving Social Security payments, only 9% had SSI. Furthermore, 18% of the New York Hospital group, compared with 10% of the Lenox Hill group, felt that their income was "not enough" to meet expenses. Perceived Health Status and Disability Since there was no medical assessment of health made by a physician, questions dealing Vol. 17, No. 4,1977
with the respondents' health were purely subjective. However, Maddox's (1964) study of the self-assessment of health in an elderly group demonstrated that approximately twothirds had a "reality orientation" in the subjective evaluation of their health. Similarly, the classic study by Shanas (1968) reported that, The self-evaluation that old people make of their health is highly correlated with their reports of restrictions on mobility, their sensory impairments, and their overall capacity scores. In general, if an old person says his health is poor, he has some physical basis for this self-judgment. As indicated in Table 2 we also found this to be true. Our assumption that the NYH respondents were in worse health than the NYH group was supported by the data. Thirty percent of the NYH group, compared with only 10% of the LH group, regarded their health as "poor." Conversely, almost one-half of the LH respondents felt that they were in "good" or "excellent" health, compared with 37% of the NYH group. Disability was measured by means of an index similar to the Townsend Index of Functional Ability (1963), which included questions concerning the amount of difficulty encountered in activities such as walking outdoors, walking up steps, washing, dressing, and cutting toenails. The NYH group not only felt that they were in poorer health, they also felt more disabled than the LH group — 43% reported "moderate" or "severe" disability, in comparison with 11% among the LH group. In terms of the total sample, 85% of those who indicated "no" or "mild" disability also reported their health as "excellent" or "good." Physician Visits and Hospitalizations
The data for physician visits (including clinic visits) made during the 12-month study period are indicative of the relative health needs of the two groups. Among the LH group seeing private physicians, 47% reported up to four visits; 24% had five to nine visits; 29% had more than ten visits. However, for the NYH group seen by clinic physicians, a significantly higher proportion had a greater number of visits—while 17% made up to four visits, 4 1 % reported five to nine visits, and another 4 1 % had more than ten visits. The data on hospitalizations also suggest that the LH respondents are healthier —only 12% had
343
Table 2 (Continued)
Table 2. Selected Medical Care Characteristics According to Croup: Percentage Distributions.
Medical Care Characteristics
Interview Location New York Lenox Hill Hospital Ambulatory Neighborhood Association Services (N = 151) (N = 100)
Usual Source Private MD New York Hospital Lenox Hill Hospital Other NA
4.6 91.4 — 4.0
Medical Care Characteristics Third Party Payment Medicare Medicaid Other insurance Waiting Time to See MD 0-30 minutes 31-60 60+ NA Seen by Same MD at Re-visits
47.0 16.0 6.0 21.0 10.0
Utilization of Source of Care Less than 10 years 54.3 More than 10 years 45.7 Health Status Excellent/Good 37.1 Fair 33.1 Poor 29.8 Physician Visits Last 12 Months Less than 4 17.2 4-9 40.9 10+ 40.9 Perceived Disability Mild 56.8 Moderate 35.8 Severe 7.4 35.8 Hospitalized During 1974 Mode of Travel to Source of Medical Care Walk 47.0 Bus 34.4 Other 18.6 Travel Time Less than 30 minutes 90.7 More than 30 minutes 9.3 Difficulty Getting to Physician (Total) 38.4 Due to disability 35.8 Other 2.6 Escort Needed 29.1 Medical Care Source: Sudden Illness Day Night Private physician 4.0 4.6 Clinic/ER 51.7 41.7 Friend/Relative 21.9 21.2 Police/Ambulance 10.6 17.2 Do without 4.6 5.3 Other 6.6 9.3 NA 0.7 0.7 Difficulty re: Payment of Medical Bills 30.8 Delay Medical Care Due to Cost Never 88.1 Seldom 6.6 Sometimes 4.0 Usually 13
66.0 34.O
89.4 39.1 38.3
89.0 18.0 48.0
21.2 38.4 35.1 5.3
50.0 14.0 28.0 8.0
68.2
75.0
been hospitalized, in contrast with 36% of the NYH group.
49.0 41.0 10.0
47.0 24^0 29.0 89.0 10.0 1.0 12.0
47.0 38.0 15.0 85.0 15.0 21.0 11.0 10.0 12.0 Day 36.0 39.0 15.0 7.0 1.0 2.0 -
Interview Location New York Hospital Lenox Hill Ambulatory Neighborhood Services Association (N = 151) (N = 100)
Night 18.0 40.0 18.0 18.0 4.0 2.0 -
Access to Medical Care For the purposes of this study, access to medical care was viewed in terms of physical effort, travel time, and travel costs. On the Upper East Side, where public transportation is relatively good, access to medical care did not appear to be restricted by mode of travel, time, or cost of transportation. Ninety percent of the respondents spent less than 30 minutes in one-way travel, and for 86% the cost was 50 cents or less. Almost one-half (47%) were able to walk to their usual source of medical care, while 36% used buses. Taxis and private cars were used by 12%; 3 LH respondents used the subway. The ambulette was mentioned by 2%. Although transportation does not appear to be problematic with respect to their access to medical care, 38% of the NYH and 2 1 % of the LH group indicated that they experienced difficulty getting to medical care. This difficulty was due to physical disability —36% of the NYH and 11% of the LH elderly specifically mentioned physical impairment interfering with their access to medical care. In fact, 29% of the NYH group felt the need for an escort, compared with 12% of the LH group, thus emphasizing the mobility problem of the elderly in general, and the poorer health status of the NYH elderly.
46.0
62.0 6.0 24.0 8.0
Health Care Utilization and Satisfaction with Medical Care When asked, "Where do you usually go for medical care?" almost one-half of the LH group indicated private physicians, 16% 344
The Gerontologist
named the New York Hospital, and 27% mentioned other hospitals in the New York City area; 10% had no usual source for medical care. Not surprisingly, 9 1 % of the NYH group named the New York Hospital, while other hospitals accounted for 4%, and 5% went to private physicians for their "usual source of care." When we inquired as to the length of time that they had been utilizing their "usual source" of medical care, we discovered that more than one-third of each group had been with the same physician or facility for more than 15 years. Among all respondents, 84% were either "very satisfied" or "satisfied" with their physician and 86% felt that their physician "always" or "usually" understood their health problems. The treatment setting did not appear to influence satisfaction—whether the respondents were seen in a private practice or treated in the hospital clinic, there were negligible differences. On those occasions when they had to remain in bed, the majority (53%) mentioned that family members were available for assistance, 16% depended upon friends and neighbors, and 6% relied upon agencies, such as the Visiting Nurse Service. It is striking that one-fourth of the respondents indicated that they had no one to care for them if they had to remain in bed. In order to get some idea of where the elderly would turn in case of sudden illness, we asked, "If you got sick and needed medical care during the day, what would you do?" and "If you got sick and needed medical care after hours, on weekends, or holidays, what would you do?" The interviewers reported that many respondents were startled by this question, and had to give it more thought than other questions. Within each group a majority said that they would contact a hospital —either the clinic or emergency room —in case of sudden illness. Approximately one-fifth indicated that they would call upon a friend or relative. Day or night, about 4% of the NYH group would call a private physician. Among the LH respondents, 36% would call their physician during the day, but only 18% would call him at night. During the day approximately 10% of the NYH and 7% of the LH group would call the police emergency number; at night this proportion increases to 17%. Only 5% of the respondents said they would not seek medical assistance. Vol. 17, No. 4,1977
Financing of Medical Care In terms of paying for medical care, 89% of the total study sample relied upon Medicare to help offset their medical expenses, and 43% had additional medical insurance such as Senior Care. Since a high proportion of the respondents lived on fixed incomes, ifwas expected that as the number of physician visits increased there would be greater difficulty in paying the deductibles. Among 133 respondents reporting fewer than seven physician visits, 37% encountered some difficulty meeting their medical expenses; the proportion increases to 60% among the 118 elderly reporting seven or more physician visits. Although the Medicaid patients did not express concern about medical payments, a high proportion (70%) of the non-Medicaid respondents reported difficulties in meeting the costs of care. The data also suggested that those receiving Medicaid are less likely to delay seeking medical care (cf. Kent 1972; Tissue 1972). Health Facility for the Elderly Among a sample of elderly persons, one would expect some interest in a hospitalbased facility that would be devoted solely to their health and medical care needs. As shown in Table 3, whether their perceived Table. 3. Respondents' Perceived Need for a "Geriatric" Clinic According to Selected Characteristics: Percentage Distributions (N = 251).
Characteristics New York Hospital Lenox Hill Neighborhood Association Male Female Seen by same MD Seen by two or more MD's Mild disability Moderate disability Severe disability Difficulty paying medical bills No difficulty paying medical Bills Health status Excellent/good Fair Poor Clinic waiting time 0-30 minutes 31-60 minutes
345
60 +
Response Toward "Geriatric" Clinic Positive Negative 14.6
85.4
57.0 26.7 33.9 30.9 15.7 33.5 27.0 25.0 42.9
43.0 73.3 66.1 69.1 84.3 66.5 73.0 75.0 57.1
25.8
74.2
37.9 34.1 30.9
62.1 65.9 69.1
41.7 19.4 38.9
58.3 80.6 61.1
health status was excellent, fair, or poor, approximately two-thirds did not want a geriatric clinic. Although the differences were not statistically significant, the findings reveal that the more severe their disability or the poorer their health status, the less the perceived need for such a clinic. It is of some interest to note that among the LH group, with its high proportion of elderly utilizing private physicians, 57% were in favor of a geriatric clinic, compared with only 15% among the NYH group. In general, those respondents who expressed a preference for a geriatric clinic were likely to be female, treated by a private physician, or experiencing difficulty meeting the expenses of medical care. It is curious that the elderly who were being treated by the same physician at each revisit were more receptive to the idea of a geriatric clinic than those who were treated by two or more physicians. Summary and Implications
The purpose of this study was to describe the medical care needs and medical care utilization patterns of 251 ambulatory elderly residing within the service area of The New York Hospital, located on Manhattan's Upper East Side. Two selected groups of elderly were studied by means of pre-coded questionnaire interviews: 100 residents participating in the social activities of the Lenox Hill Senior Citizen Center; 151 ambulatory patients attending the clinics at The New York Hospital. Those in worse health and with lower incomes were at the NYH. Both groups were generally satisfied with the medical care they received; two-thirds of the total sample were not in favor of a geriatric facility. Furthermore, two-thirds of those who had been utilizing hospital clinics were not favorably disposed toward a specialized clinic for the elderly. This suggests that the elderly do not want to relinquish a set medical and social pattern for a perceived change of medical services and social surroundings that a geriatric facility might offer. The fact that more than one-third of the Lenox Hill group and two-fifths of the New York Hospital group had been utilizing the same source of medical care (physician or clinic) for 15 years or longer, and that most
were generally satisfied with their medical care, should not obscure problems faced by the elderly in securing medical care. It should be kept in mind that the Lenox Hill group were relatively healthy and the New York Hospital group were receiving medical treatment. However, there exist a vast number of elderly in the community who are homebound (whether from disability or fear), isolated, and perhaps without knowledge of the health care system. In view of this larger population there are provocative implications. In planning for the elderly, much more consideration must be given to the problem of access to medical services. In terms of initial access to the system, increased attention should be directed toward providing information about medical care and services for all members of the elderly community. As this study points out, in particular, there is a need to provide information and services that would be required in the event of sudden illness or medical emergency. With respect to physical access to medical care, the need for escort services and transportation increases as one gets older and physical impairment intensifies. Therefore it is reasonable to expect that the needs of the elderly are greater than the findings suggest.
References
Cantor, M., & Mayer, M. Questionnaire study of the elderly. New York City Office for the Aging, New York, 1974. (mimeo) Cantor, M., & Mayer, M. Health and the inner city elderly. Gerontologist, 1976, 76,17-25. Kent, D., & Hirsch, C. Needs and use of services among Negro and white aged, Vol. II. Pennsylvania State Univ., University Park, 1972. Maddox, C. L. Self-assessment of health status: A longitudinal study of selected elderly subjects, journal of Chronic Diseases, 1964, 17, 449-460. Shanas, E., Townsend, P., Wedderburn, D., Friis, H., Milhoj, P., & Stehouwer, J. Old people in three industrial societies. Atherton Press, New York, 1968. Tissue, T. Patterns of aging on welfare. Dept. of Welfare, Sacramento, 1972. Townsend, P. Measuring incapacity for self-care. In R. Williams, C. Tibbitts, & W. Donahue (Eds.), Processes of aging: Social and psychological aspects. Atherton Press, New York, 1963. Univ. of Rochester School of Medicine & Dentistry. Health Care of the Aged Study: A study of the physical and mental health care needs of older people in Monroe County, New York, Rochester, 1968.
346
The Gerontologist
Health Care in a Selected Urban Elderly Population Utilization Patterns and Perceived Needs Marilyn Iris Auerbach, AMLS.2 David W. Gordon, PhD,3 Alice Ullmann, CSW,4 and Michael J. Weisel, CSW5 The New York Hospital, a large voluntary teaching hospital affiliated with Cornell University Medical College, is located on the upper East Side of Manhattan, one of the wealthiest urban areas in the country. The immediate service area of the hospital (59th to 96th Sts., East River to Fifth Ave.) has a population of approximately 200,000, a large array of medical institutions, and a high ratio of physicians per 100,000 population. However, this area also has a higher than average proportion of elderly —17% are age 65 and older, compared with a city-wide average of 14%.
Many of these elderly have low incomes (15% of the area's 34,000 elderly residents are below the Federally designated poverty level) and, more often than not, live in tenements adjacent to new, luxury high-rise apartment buildings. Background of the Study
Large medical institutions similar to the New York Hospital-Cornell Medical Center serve the needs of patients throughout the city and surrounding region by providing specialized and advanced medical treatment. Since these institutions cannot survive within a vacuum, it is especially worthwhile to be responsive to particular needs, such as those ex'This study was supported in part by a grant from the New York Metropolitan Regional Medical Program. 'Assistant in Research, Dept. of Public Health, Room A-631, Cornell Univ. Medical College, 1300 York Ave., New York 10021. 'Research Associate. 'Assistant Professor of Social Work. 'Community Social Worker.
Vol.17, No. 4, 1977
pressed by members of community boards and representatives of committees, insofar as they relate to matters of health. At a number of meetings devoted to discussions of the role of the medical center, it was suggested that ambulatory health care for the elderly was deficient and that the health care that was provided lacked continuity. It was stated that many homebound elderly were unable to get physicians to make home visits, that both homebound and ambulatory elderly were concerned and confused about their coverage under Medicare and Medicaid, and that those who did find their way to the hospital were often sent from one clinic to another and were thus "lost in the shuffle." A:; Cantor and Mayer (1976) cogently observed,
On the face of it, older New Yorkers would seem to have ample resources to meet their considerable health needs. But for many residents of the city, particularly those who are old and poor, the system's magnitude and complexity make it confusing, insensitive, forbidding and often impenetrable.
The hospital and community representatives agreed that many of the health needs of the elderly poor were not being optimally met, but there was disagreement on the mode of delivery. In particular, local representatives suggested the establishment of a comprehensive geriatric health facility within the existing ambulatory care service of the hospital. Given the lack of empirical data about
341
the patients' desire for a special geriatric clinic, representatives of the medical center conducted a study in order to identify and compare the perceived health care needs and medical care utilization patterns of two selected groups—those participating in a senior citizen center and those involved in a hospital-based clinic. Description of the Setting and Assessment
The interviews were conducted at two locations: (1) The Lenox Hill Senior Citizen Center, sponsored by the Lenox Hill Neighborhood Association, which provides a wide range of services and programs for the elderly, including a Title XX hot lunch program. The Senior Citizen Center is located two blocks from The New York Hospital; (2) The New York Hospital's Ambulatory Services (out-patient department), which provides a complete range of medical and ancillary services for approximately 220,000 patient-visits per year. The Lenox Hill group (LH) consisted of elderly residents participating in social activities, while those in the New York Hospital group (NYH) consisted of elderly ambulatory patients. A certified social worker or supervised, trained volunteers conducted 251 interviews of persons who were 60 years of age and older and resided within the service area of the hospital. At the New York Hospital, interviewers selected 151 patients who were registered with the clinic clerk and seen by physicians in the General Medical Clinic or other clinics. At the Lenox Hill location, 100 respondents were chosen from those participating in the Title XX program or infrequent walk-in patrons. With respect to these settings, it should be kept in mind that we expected that the LH group would be in better health than the NYH group. The precoded questionnaire was the same for each group, with the exception of four questions specific to health care delivery at the New York Hospital, which were applicable to the NYH sample. Respondent information was obtained through a guided but flexible interview technique which utilized closed and open-ended questions, some adapted from earlier studies (Cantor & Mayer, 1974; Maddox, 1964; Townsend, 1963; Univ. of Rochester, 1968). The questionnaire was designed to provide general demographic information, as well as specific data concerning
health status, access to medical care, medical care utilization, continuity of care, financing of medical care, and satisfaction with health care. Living Arrangements Since we expected that the residential migration of the elderly population had been negligible, we inquired about the length of time each respondent had lived in his present apartment. The data revealed long-term residential stability for both groups —82% of the total sample had been living in the same apartment for 6 years or longer, and 6 1 % for Table 1. Selected Demographic Characteristics According to Croup: Percentage Distribution.
Demographic Characteristics Age Range: Mean: 60-74 75 + Sex Male Female Race White Black Hispanic Other Housing Apartment No. years in present apartment Under 10 11-20
20 + Elevatoror 1st floor 2-3 flight walk-up 3+ flight walk-up Occupation Blue collar White collar Housewife Income - Current Source Social Security SSI Other Currently employed Income - Perceived Sufficiency Comfortable Just enough Not enough
342
Interview Location New York Lenox Hill Hospital Ambulatory Neighborhood Services Association (N = 151) (N = 100)
60-91 years 72.9 years 55% 45
60-94 years 72.1 years 65% 35
37.1 62.9
30.0 70.0
94.0 3.3 2.0 0.7
98.0 — — 2.0
98.7
91.0
41.7 21.9 36.4 43.3 42.0 14.7
34.0 24.0 42.0 30.0 49.0 21.0
65.0 20.0 15.0
58.0 33.0 9.0
49.7 32.5 17.8 12.6
74.0 9.0 17.0 12.0
21.0 61.0 18.0
17.0 73.0 10.0
The Gerontologist
more than 10 years. As shown in Table 1, 30% had been residing in the same place for 30 years or more. Only 11 persons (4.4%) resided in rooms instead of apartments. Slightly more than one-half (57%) lived alone, 27% lived with their spouses, 8% with a sibling or friend, and 6% with their children. Since we were studying an elderly ambulatory population, it was of interest to discover that approximately 45% of the total sample had to walk two or more flights to reach their apartments; 17% occupied walk-ups of three or more flights. Although 7 1 % expressed satisfaction with their living arrangements, 18% who indicated dissatisfaction were usually those elderly living alone and reporting insufficient income. Of particular interest is the finding that one-quarter of those living in the same dwelling for over 30 years were dissatisfied with their living conditions. Dissatisfaction with living arrangements also increased in relationship to the number of flights an elderly person had to walk to reach his apartment. Most of the respondents indicated that they spent more than one-half of their income for rent and the lack of extra dollars kept them from moving from the upper floors of deteriorating buildings to those better maintained buildings with elevators and higher rents. Faced with the prospect of either remaining in unsatisfactory housing or moving to a strange neighborhood away from friends and acquaintances, known streets and shops, most of these elderly seemingly chose to live with the familiar. The lack of adequate income also seemed to have special relevance for the NYH group, since those who reported low income also reported worse health —a pattern found in other studies in recent years (Cantor & Mayer 1976; Tissue, 1972). Fifty percent of the NYH sample received their income from Social Security; additionally, 33% was eligible for and received funds through Supplementary Security Income (SSI). The data for the LH group revealed that, while 74% mentioned that they were receiving Social Security payments, only 9% had SSI. Furthermore, 18% of the New York Hospital group, compared with 10% of the Lenox Hill group, felt that their income was "not enough" to meet expenses. Perceived Health Status and Disability Since there was no medical assessment of health made by a physician, questions dealing Vol. 17, No. 4,1977
with the respondents' health were purely subjective. However, Maddox's (1964) study of the self-assessment of health in an elderly group demonstrated that approximately twothirds had a "reality orientation" in the subjective evaluation of their health. Similarly, the classic study by Shanas (1968) reported that, The self-evaluation that old people make of their health is highly correlated with their reports of restrictions on mobility, their sensory impairments, and their overall capacity scores. In general, if an old person says his health is poor, he has some physical basis for this self-judgment. As indicated in Table 2 we also found this to be true. Our assumption that the NYH respondents were in worse health than the NYH group was supported by the data. Thirty percent of the NYH group, compared with only 10% of the LH group, regarded their health as "poor." Conversely, almost one-half of the LH respondents felt that they were in "good" or "excellent" health, compared with 37% of the NYH group. Disability was measured by means of an index similar to the Townsend Index of Functional Ability (1963), which included questions concerning the amount of difficulty encountered in activities such as walking outdoors, walking up steps, washing, dressing, and cutting toenails. The NYH group not only felt that they were in poorer health, they also felt more disabled than the LH group — 43% reported "moderate" or "severe" disability, in comparison with 11% among the LH group. In terms of the total sample, 85% of those who indicated "no" or "mild" disability also reported their health as "excellent" or "good." Physician Visits and Hospitalizations
The data for physician visits (including clinic visits) made during the 12-month study period are indicative of the relative health needs of the two groups. Among the LH group seeing private physicians, 47% reported up to four visits; 24% had five to nine visits; 29% had more than ten visits. However, for the NYH group seen by clinic physicians, a significantly higher proportion had a greater number of visits—while 17% made up to four visits, 4 1 % reported five to nine visits, and another 4 1 % had more than ten visits. The data on hospitalizations also suggest that the LH respondents are healthier —only 12% had
343
Table 2 (Continued)
Table 2. Selected Medical Care Characteristics According to Croup: Percentage Distributions.
Medical Care Characteristics
Interview Location New York Lenox Hill Hospital Ambulatory Neighborhood Association Services (N = 151) (N = 100)
Usual Source Private MD New York Hospital Lenox Hill Hospital Other NA
4.6 91.4 — 4.0
Medical Care Characteristics Third Party Payment Medicare Medicaid Other insurance Waiting Time to See MD 0-30 minutes 31-60 60+ NA Seen by Same MD at Re-visits
47.0 16.0 6.0 21.0 10.0
Utilization of Source of Care Less than 10 years 54.3 More than 10 years 45.7 Health Status Excellent/Good 37.1 Fair 33.1 Poor 29.8 Physician Visits Last 12 Months Less than 4 17.2 4-9 40.9 10+ 40.9 Perceived Disability Mild 56.8 Moderate 35.8 Severe 7.4 35.8 Hospitalized During 1974 Mode of Travel to Source of Medical Care Walk 47.0 Bus 34.4 Other 18.6 Travel Time Less than 30 minutes 90.7 More than 30 minutes 9.3 Difficulty Getting to Physician (Total) 38.4 Due to disability 35.8 Other 2.6 Escort Needed 29.1 Medical Care Source: Sudden Illness Day Night Private physician 4.0 4.6 Clinic/ER 51.7 41.7 Friend/Relative 21.9 21.2 Police/Ambulance 10.6 17.2 Do without 4.6 5.3 Other 6.6 9.3 NA 0.7 0.7 Difficulty re: Payment of Medical Bills 30.8 Delay Medical Care Due to Cost Never 88.1 Seldom 6.6 Sometimes 4.0 Usually 13
66.0 34.O
89.4 39.1 38.3
89.0 18.0 48.0
21.2 38.4 35.1 5.3
50.0 14.0 28.0 8.0
68.2
75.0
been hospitalized, in contrast with 36% of the NYH group.
49.0 41.0 10.0
47.0 24^0 29.0 89.0 10.0 1.0 12.0
47.0 38.0 15.0 85.0 15.0 21.0 11.0 10.0 12.0 Day 36.0 39.0 15.0 7.0 1.0 2.0 -
Interview Location New York Hospital Lenox Hill Ambulatory Neighborhood Services Association (N = 151) (N = 100)
Night 18.0 40.0 18.0 18.0 4.0 2.0 -
Access to Medical Care For the purposes of this study, access to medical care was viewed in terms of physical effort, travel time, and travel costs. On the Upper East Side, where public transportation is relatively good, access to medical care did not appear to be restricted by mode of travel, time, or cost of transportation. Ninety percent of the respondents spent less than 30 minutes in one-way travel, and for 86% the cost was 50 cents or less. Almost one-half (47%) were able to walk to their usual source of medical care, while 36% used buses. Taxis and private cars were used by 12%; 3 LH respondents used the subway. The ambulette was mentioned by 2%. Although transportation does not appear to be problematic with respect to their access to medical care, 38% of the NYH and 2 1 % of the LH group indicated that they experienced difficulty getting to medical care. This difficulty was due to physical disability —36% of the NYH and 11% of the LH elderly specifically mentioned physical impairment interfering with their access to medical care. In fact, 29% of the NYH group felt the need for an escort, compared with 12% of the LH group, thus emphasizing the mobility problem of the elderly in general, and the poorer health status of the NYH elderly.
46.0
62.0 6.0 24.0 8.0
Health Care Utilization and Satisfaction with Medical Care When asked, "Where do you usually go for medical care?" almost one-half of the LH group indicated private physicians, 16% 344
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named the New York Hospital, and 27% mentioned other hospitals in the New York City area; 10% had no usual source for medical care. Not surprisingly, 9 1 % of the NYH group named the New York Hospital, while other hospitals accounted for 4%, and 5% went to private physicians for their "usual source of care." When we inquired as to the length of time that they had been utilizing their "usual source" of medical care, we discovered that more than one-third of each group had been with the same physician or facility for more than 15 years. Among all respondents, 84% were either "very satisfied" or "satisfied" with their physician and 86% felt that their physician "always" or "usually" understood their health problems. The treatment setting did not appear to influence satisfaction—whether the respondents were seen in a private practice or treated in the hospital clinic, there were negligible differences. On those occasions when they had to remain in bed, the majority (53%) mentioned that family members were available for assistance, 16% depended upon friends and neighbors, and 6% relied upon agencies, such as the Visiting Nurse Service. It is striking that one-fourth of the respondents indicated that they had no one to care for them if they had to remain in bed. In order to get some idea of where the elderly would turn in case of sudden illness, we asked, "If you got sick and needed medical care during the day, what would you do?" and "If you got sick and needed medical care after hours, on weekends, or holidays, what would you do?" The interviewers reported that many respondents were startled by this question, and had to give it more thought than other questions. Within each group a majority said that they would contact a hospital —either the clinic or emergency room —in case of sudden illness. Approximately one-fifth indicated that they would call upon a friend or relative. Day or night, about 4% of the NYH group would call a private physician. Among the LH respondents, 36% would call their physician during the day, but only 18% would call him at night. During the day approximately 10% of the NYH and 7% of the LH group would call the police emergency number; at night this proportion increases to 17%. Only 5% of the respondents said they would not seek medical assistance. Vol. 17, No. 4,1977
Financing of Medical Care In terms of paying for medical care, 89% of the total study sample relied upon Medicare to help offset their medical expenses, and 43% had additional medical insurance such as Senior Care. Since a high proportion of the respondents lived on fixed incomes, ifwas expected that as the number of physician visits increased there would be greater difficulty in paying the deductibles. Among 133 respondents reporting fewer than seven physician visits, 37% encountered some difficulty meeting their medical expenses; the proportion increases to 60% among the 118 elderly reporting seven or more physician visits. Although the Medicaid patients did not express concern about medical payments, a high proportion (70%) of the non-Medicaid respondents reported difficulties in meeting the costs of care. The data also suggested that those receiving Medicaid are less likely to delay seeking medical care (cf. Kent 1972; Tissue 1972). Health Facility for the Elderly Among a sample of elderly persons, one would expect some interest in a hospitalbased facility that would be devoted solely to their health and medical care needs. As shown in Table 3, whether their perceived Table. 3. Respondents' Perceived Need for a "Geriatric" Clinic According to Selected Characteristics: Percentage Distributions (N = 251).
Characteristics New York Hospital Lenox Hill Neighborhood Association Male Female Seen by same MD Seen by two or more MD's Mild disability Moderate disability Severe disability Difficulty paying medical bills No difficulty paying medical Bills Health status Excellent/good Fair Poor Clinic waiting time 0-30 minutes 31-60 minutes
345
60 +
Response Toward "Geriatric" Clinic Positive Negative 14.6
85.4
57.0 26.7 33.9 30.9 15.7 33.5 27.0 25.0 42.9
43.0 73.3 66.1 69.1 84.3 66.5 73.0 75.0 57.1
25.8
74.2
37.9 34.1 30.9
62.1 65.9 69.1
41.7 19.4 38.9
58.3 80.6 61.1
health status was excellent, fair, or poor, approximately two-thirds did not want a geriatric clinic. Although the differences were not statistically significant, the findings reveal that the more severe their disability or the poorer their health status, the less the perceived need for such a clinic. It is of some interest to note that among the LH group, with its high proportion of elderly utilizing private physicians, 57% were in favor of a geriatric clinic, compared with only 15% among the NYH group. In general, those respondents who expressed a preference for a geriatric clinic were likely to be female, treated by a private physician, or experiencing difficulty meeting the expenses of medical care. It is curious that the elderly who were being treated by the same physician at each revisit were more receptive to the idea of a geriatric clinic than those who were treated by two or more physicians. Summary and Implications
The purpose of this study was to describe the medical care needs and medical care utilization patterns of 251 ambulatory elderly residing within the service area of The New York Hospital, located on Manhattan's Upper East Side. Two selected groups of elderly were studied by means of pre-coded questionnaire interviews: 100 residents participating in the social activities of the Lenox Hill Senior Citizen Center; 151 ambulatory patients attending the clinics at The New York Hospital. Those in worse health and with lower incomes were at the NYH. Both groups were generally satisfied with the medical care they received; two-thirds of the total sample were not in favor of a geriatric facility. Furthermore, two-thirds of those who had been utilizing hospital clinics were not favorably disposed toward a specialized clinic for the elderly. This suggests that the elderly do not want to relinquish a set medical and social pattern for a perceived change of medical services and social surroundings that a geriatric facility might offer. The fact that more than one-third of the Lenox Hill group and two-fifths of the New York Hospital group had been utilizing the same source of medical care (physician or clinic) for 15 years or longer, and that most
were generally satisfied with their medical care, should not obscure problems faced by the elderly in securing medical care. It should be kept in mind that the Lenox Hill group were relatively healthy and the New York Hospital group were receiving medical treatment. However, there exist a vast number of elderly in the community who are homebound (whether from disability or fear), isolated, and perhaps without knowledge of the health care system. In view of this larger population there are provocative implications. In planning for the elderly, much more consideration must be given to the problem of access to medical services. In terms of initial access to the system, increased attention should be directed toward providing information about medical care and services for all members of the elderly community. As this study points out, in particular, there is a need to provide information and services that would be required in the event of sudden illness or medical emergency. With respect to physical access to medical care, the need for escort services and transportation increases as one gets older and physical impairment intensifies. Therefore it is reasonable to expect that the needs of the elderly are greater than the findings suggest.
References
Cantor, M., & Mayer, M. Questionnaire study of the elderly. New York City Office for the Aging, New York, 1974. (mimeo) Cantor, M., & Mayer, M. Health and the inner city elderly. Gerontologist, 1976, 76,17-25. Kent, D., & Hirsch, C. Needs and use of services among Negro and white aged, Vol. II. Pennsylvania State Univ., University Park, 1972. Maddox, C. L. Self-assessment of health status: A longitudinal study of selected elderly subjects, journal of Chronic Diseases, 1964, 17, 449-460. Shanas, E., Townsend, P., Wedderburn, D., Friis, H., Milhoj, P., & Stehouwer, J. Old people in three industrial societies. Atherton Press, New York, 1968. Tissue, T. Patterns of aging on welfare. Dept. of Welfare, Sacramento, 1972. Townsend, P. Measuring incapacity for self-care. In R. Williams, C. Tibbitts, & W. Donahue (Eds.), Processes of aging: Social and psychological aspects. Atherton Press, New York, 1963. Univ. of Rochester School of Medicine & Dentistry. Health Care of the Aged Study: A study of the physical and mental health care needs of older people in Monroe County, New York, Rochester, 1968.
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