Telephone hotline for aging: Information needs,quality of service,and insights

Abstract

This study examined the reasons for use and the utility of an aging-focused telephone hotline. The most common topic of inquiry was care, followed by referrals for institutional placement and financial queries. Advice from hotline professionals was reported to be useful and helpful. Yet the issue of the query was not resolved in half of the cases. Some queries may be addressed by enhancing hotline procedures, but others reflect general unmet needs that require wider systematic social changes in the information, system, and financial domains. Analysis of hotline calls can be useful for identifying areas, both for improvement for the hotline and for society.

Keywords

Care needs caregivers hotline information needs older adults

Introduction

Older adults and their caregivers have significant information needs and, as individuals age, they or their caregivers face technical difficulties in accessing information systems (Clancy Dollinger and Chwalisz, 2011; Larner, 2011). Reported barriers include access to the Internet, knowledge of how to access needed information, as well as attitudes toward help-seeking and problem solving skills. Although older adults’ access to the Internet has increased in recent decades, they still have lower levels of access than other adults and are often limited in both their Internet literacy and their willingness to utilize such technology (Casado Muñoz et al., 2015; Denvir et al., 2014). In addition, lower access is associated with lower socioeconomic status (Silver, 2014). Telephone hotlines or social service call centers are therefore important alternative resources that can provide for information needs by utilizing a comfortable and familiar medium at a time and place that is flexible and convenient for the caller (Clancy Dollinger and Chwalisz, 2011). Information needs among informal caregivers of older persons with chronic health conditions have been described (Hirakawa et al., 2011; Washington et al., 2011). However, knowledge of the nature of the needs of hotline callers, as well as of which needs are or are not being met by hotline services, is limited.

Multiple telephone-based services have been studied. For example, the term ‘telephone support’ refers to counseling and support to family caregivers by professional caregivers (Magnusson et al., 2004) and to medical consultations by health care professionals to patients, family caregivers, and families (Stern et al., 2012). Telephone calls to patients that are initiated by clinicians are referred to as telephone care (Wasson et al., 1992). Unlike these services, telephone hotlines are typically staffed by lay counselors or trained volunteers, offering general information, education, and referrals (e.g. counseling services and mental health services) rather than direct professional support to various populations (Coyne, 1991; King et al., 2003; Silverstein et al., 1993; Wunsch-Hitzig et al., 2002). Some hotlines, however, are operated by professionals such as general practitioners, nurses, and social workers (Lechner and De Vries, 1996; Montazeri et al., 1999). In this article, we will use the terms hotline and call center interchangeably, denoting agencies that provide telephone-based information and short-term counseling services.

Telephone services have been found to meet multiple needs of caregivers, such as their needs for information/education, referrals, convenient accessible support, emotional support, and a sense of companionship (Salfi et al., 2005), as well as increasing family cooperation and decreasing stress in caregivers (Serrate et al., 2001). In a longitudinal intervention study of 130 caregivers, telephone support utilization was related to lower levels of stress and increased social role functioning at post-intervention and at six-month follow-up. However, it was also associated with higher levels of psychological distress at post-intervention when compared to baseline (Clancy Dollinger and Chwalisz, 2011). This suggests that telephone services may be useful in particular domains, but do not address all of the callers’ needs. Indeed, a meta-analytic review of 13 studies of telephone triage recommendations found that 38 percent of the patients overall did not comply with care recommendations, and that rates of noncompliance were higher (56%) for non-urgent care recommendations and lower (21%) for recommendations and advice to perform self-care (Purc-Stephenson and Thrasher, 2012).

Studies on hotline callers’ satisfaction with services provided include studies on cancer hotlines (Lechner and De Vries, 1996; Montazeri et al., 1999; Reubsaet et al., 2006) and AIDS hotlines (Bos et al., 2004; Mevissen et al., 2012). Others have examined the quality of response in a gambling hotline (Ferland et al., 2013). As for old age, telephone hotline services specializing in Alzheimer’s disease and related disorders had positive levels of satisfaction with the information and referrals received (Coyne, 1991). In addition, callers’ ratings of helpfulness of the information provided were mostly positive in domains such as family support group and nursing home information, but were mostly negative in the domains of financial issues, respite care, and other crisis intervention (Silverstein et al., 1993). In the same study, over half of the referrals relating to respite care, nursing home information, in-home services, and diagnostic evaluation were not utilized by callers (Silverstein et al., 1993). Caregivers of older persons have multiple information needs that are not restricted to disease-related information and include questions regarding institutional care, nutrition, and stress management (Hirakawa et al., 2011). These results notwithstanding, findings on hotlines utilization and the quality of information provided are scant and inconclusive.

In order to further understand the needs of aging-focused hotline callers and the avenues to address them, we examine the characteristics of hotline utilization and the quality of responses provided in a sample of 42 Israeli callers to an aging information hotline service.

Methods

Participants and procedure

Participants were 42 persons between the ages of 26 and 79 who called the Reuth-Eshel information center (http://www.familycare.co.il) during the two months prior to the study. The center provides information and professional guidance on issues related to old age. Responses are given by social workers and by specialists in geriatrics, rehabilitation medicine, and nursing. Contact details were provided by the Reuth-Eshel hotline. Participants were approached by phone between May 2011 and November 2011, which was up to two months after their original inquiry. Participation was voluntary, and it was made clear that responses would be kept confidential. Informed consent was verbally clarified at the beginning of the telephone interview.

Assessments

Data were collected using a brief telephone questionnaire developed for this study.

Demographics

Demographics included age and gender of participant and of the older person regarding whom the query was made (when applicable).

Hotline utilization

Information source

One item asked where participants heard about the information center (Internet, radio, recommendations of acquaintances, newspaper, professionals, and prior acquaintance).

Topic of inquiry

Participants were asked to indicate their topic of inquiry (community, care, rehabilitation and geriatrics, professional cooperation, legal issues, Holocaust survivors’ rights, other – specify) and to provide details regarding the topic.

Satisfaction and resolution

Two items evaluated the extent of helpfulness (‘Was the help received helpful in solving the problem?’) and use of the help received (‘To what extent did you use the help received?’). Both these items were rated on a 1–5 scale (not at all, to a small extent, to a moderate extent, to a large extent, and to a very large extent). Another item evaluated whether the issue leading to the query had been resolved.

Results

The average age of callers to the information center was 49.46 years (standard deviation (SD) = 12.79; range: 26–79), with most being female (64.3%). Most of the queries (81%) involved a person other than the caller. The persons who were the focus of inquiry had a mean (SD) age of 78.18 (11.56) years, and half of them were female. Participants had heard of the Reuth-Eshel hotline through the Internet (42.85%), radio (35.71%), recommendations of acquaintances (11.9%), newspaper (7.1%), and professionals and prior acquaintance (4.8% each).

Topics of inquiry, help ratings, and resolution rates are presented in Table 1. The most common topic of inquiry was care (e.g. extending the work hours of the foreign caregiver due to health deterioration of the care receiver; care needs during hospitalization) (28.56%), followed by questions about referrals for institutional placement (26.19%), and financial queries (16.67%). The rest were individual-specific requests for information about various topics, including finding a lecturer and volunteering to host older persons during Passover.

Table 1.

Topics of inquiry, help ratings, and resolution rates (N = 42)

Topics		Was the help used?	Was the help helpful?	Unresolved queries
	% (n)	M (SD)	M (SD)	%
Total	100 (42)	4 (2.15)	4.43 (1.93)	50
Care (total)	28.56 (12)	3.8 (1.47)^a	3.91 (1.58)^b	58.3
Home care	16.66
Care needs during hospitalization: overnight monitoring	2.38
investigating medical malpractice in NH	2.38
Managing the transfer to NH	2.38
Care – general	4.76
Institutional placement	26.19 (11)	2.6 (2.06)^c	3.5 (2.07)^d	63.6
Searching for rehabilitation institutions	4.76
Searching for institutional placement for persons on ventilators	2.38
Searching for institutional placement contacts for new Israeli immigrants and immigrant citizens	2.38
Institutional placement – general	16.67
Financial rights (total)	16.66 (7)	3 (2)	3.43 (1.72)	42.9
Social security	4.76
Institutional placement	4.76
Home caregiving	4.76
Financial rights – general	2.38
Community rights and services	7.14 (3)	5 (0)^e	5 (0)^e	27.3
Rehabilitation in the community	2.38
Assistive device (walker)	2.38
Community rights and services – general	2.38
Searching for other information, about:
Holocaust survivors who contact health care services	2.38
Cognitive decline	2.38
Health decline (general)	2.38
Status of legal guardian appointment	2.38
Looking for a job	2.38
Emotional support in the community	2.38
Volunteering referral	2.38
Health care referral	2.38
Finding a lecturer	2.38

SD: standard deviation; NH: nursing home.

Help ratings are on a 1 (not at all) to 5 (to a very large extent) scale; in case of missing values, the n is indicated. In all other instances, the n is unchanged.

n = 11, ^bn = 12, ^cn = 10, ^dn = 8, and ^en = 2.

Overall, help received was, on average, reported to be used to a large extent (4.00), and it was helpful to a large to very large extent (4.43). With regard to the individual categories, information provided by the hotline was considered helpful from a moderate to large extent for care (3.91), institutional placement (3.50), and financial topics (3.43) and to a very large extent for community issues (5.00). Most ratings for use of information were also positive: care = 3.8, financial = 3.00, and community = 5.0. However, while the helpfulness ratings for institutional placement were similar to those for most of the other categories, use ratings for institutional placement were lowest (2.6), and the help received was acted upon only a small to moderate extent. While the response by the call center was generally perceived as helpful and was used, the issue leading to the query was resolved in only half of the cases (Table 1).

This discrepancy between the largely positive help ratings and the low resolution rates led us to examine the open-ended items alongside quantitative information in search of barriers to successful resolution and of broader system issues. Thus, we identified (1) unmet service needs that could be addressed by changing hotline procedures and (2) general unmet needs in the Israeli society that represent barriers to resolution that cannot be addressed by hotline services. Needs where hotline responses were inadequate are demonstrated in the following examples.

Mr A is a 31-year-old man who inquired about institutional placement for his 103-year-old grandfather. The information center provided a referral to companies that refer to nursing homes. These companies receive payment for the referral from the nursing homes. He contacted the companies, but they did not provide sufficient detail about the nursing homes. So, the original referral by the hotline was not helpful. Eventually, the grandfather passed away and was not placed in a nursing home.

Mr B is a 37-year-old man who was interested in support and referral information for his 73-year-old father who had been diagnosed with cancer. He was provided with general advice such as to consult a social worker or the National Insurance Institute of Israel. He felt this general advice did not present new information and was not helpful, and so there was no point in asking for additional information. The problem was eventually solved by friends and family. Mr B stated that it is good to have the information center available and recommended providing more problem-focused advice.

These examples highlight the need to re-evaluate the scope of services provided by the hotline. In the aforementioned cases, the hotline provided referrals to other services which could assist the caller in locating the specific service required. However, either the quality of the referred services was inadequate or the callers were looking for more direct responses from the hotline. To more directly meet the needs of clients, the hotline would need to expand its own information database so that it could provide more specific and individualized information directly to callers. For example, (1) with respect to nursing home referrals, this could include initial information regarding nursing home-specific eligibility criteria and rights for such care and (2) more relevant and specific information and referrals for subpopulations, such as cancer patients, seeking support and information regarding their rights.

General unmet needs in the Israeli society are presented in Table 2 and are illustrated in the following examples.

Table 2.

General unmet needs in the Israeli society

Information

A wider public dissemination of knowledge about aging. This includes knowledge about older persons’ rights, senior citizens’ rights and access to them, and information for caregivers about cognitive decline in older persons

System

Promoting the availability of services for handling severe decline that the family considers temporary

Help in navigating the system of care and applying for services

Provision of psychological support to family caregivers regarding the transition of the older person to a nursing home, which is difficult both for the older person and the family member

Higher levels of responsiveness of care companies and quicker processing of requests

Quicker processing of requests for appointing a legal guardian

Financial

Financial benefits criteria are such that people cannot get the care they need. Older persons who require care and feel they need financial support may not be eligible for financial benefits, as in the case of Ms F and Mr H

No available low cost assisted living for older persons with low income, as in the case of Mr G

The Israeli law requiring children to pay for parents’ care is an obstacle to provision of proper care

Ms C is a 38-year-old woman who called the hotline to ask about institutional placement for a 69-year-old man. She was very confused and in need of guidance and direction, which were provided to her satisfaction by the hotline and which enabled her to successfully claim rights for the person prompting the query. Ms C says she lives in an outlying location and feels she lacks knowledge of rights concerning older persons. She adds that, had she known about the existing possibilities earlier, the situation would have been improved. This example demonstrates the need for a wider public dissemination of knowledge on aging and associated options and rights, as well as a need to better publicize the hotline as a venue that can provide this information. Presumably, had she accessed the hotline earlier, she could have prevented prior problems and confusion.

Ms D is a 44-year-old woman who called to ask about home care for an 83-year-old man and was provided with contact information of home care companies (i.e. companies that provide nursing care services for older persons who reside in the community). At three weeks following the call, they were still waiting for help from social security services (which provide funding for limited home care) and have received limited help from the home care companies. Ms D tried working with one care company and then switched to another company, which she considered to be better. Ms D commented,

The hotline should make the right connection with the agency that can help instead of the inquirer turning to them. The person with the inquiry does not know and does not sufficiently understand who are the people that need to be approached and what are the ways to handle the problem.

This demonstrates, on the one hand, the low responsiveness of home care companies and the very slow processing of requests and, on the other hand, the need for step-by-step help and guidance from the hotline representative in pursuing the recommended course of action.

Mr E is a 79-year-old man who called to ask about institutional placement for the husband of his 70-year-old sister. The husband suffers from Alzheimer’s disease and is violent towards his wife. Mr E was informed that since his nephews have an income, they are not eligible for financial support in institutional placement. (Note: In Israel, children are financially responsible for institutional placement of their parents. The state provides financial support for institutional placement only when the older person cannot perform activities of daily living and the person and his/her children are indigent.) Mr E reported that the problem has not been resolved, and that he has no more options for action. This demonstrates how the Israeli law requiring children to pay for their parents’ care can be an obstacle to provision of proper care.

Ms F is a 50-year-old woman who was interested in information on overnight monitoring services for a hospitalized 60-year-old woman. She was referred to another source, which provided satisfactory information. Due to financial reasons, the family decided not to use overnight monitoring.

Mr G is a 38-year-old man who called regarding institutional placement in a sheltered housing building for his 68-year-old father. The father is a Holocaust survivor and does not have the funds to purchase a flat. As a Holocaust survivor, the father receives some benefits but is not entitled to income support and its associated rights. Mr G was referred to another source, which he had already contacted prior to calling the hotline. He was informed that the specific housing complex he was interested in had no available units, and he was not provided with any alternatives. He did not find the referral helpful or useful, would have benefited from receiving a follow-up call and from being referred to a counselor who would help him find a solution, and felt that his father was ‘falling through the cracks’.

Mr H is a 63-year-old man who called for information on financial rights with regard to a 90-year-old man. He was offered a solution for obtaining funds by looking for a legislative loophole, specifically, to apply for financial support for diapers, since the person prompting the call is not entitled to caregiving support. Mr H found this reply unsatisfactory, inadequate, and complex. These examples demonstrate financial criteria that block access to services to older persons who need them and who consider themselves unable to afford them.

Thus, the unmet needs demonstrated by these cases represent information, system, and financial issues, as summarized in Table 2. These include, for example, the need for a wider dissemination of information on aging and ways to access it; aid to persons trying to navigate the system and apply for benefits; greater responsiveness of care companies; and financial benefits criteria that enable people to get the care they need.

Discussion

This study examined the information needs and the perceived quality of responses provided by an aging-focused hotline in a sample of 42 hotline callers. The two most common information needs related to care (e.g. home care and care needs during hospitalization) and referrals for institutional placement. These findings corroborate evidence from studies of telephone hotlines for Alzheimer’s disease, in which the most common information needs related to in-home services (Coyne, 1991) and nursing home information (Silverstein et al., 1993). Additional, less common, information needs related to financial issues (e.g. social security) and community rights and services (e.g. accessing an assistive device). Previous hotline studies have similarly found low rates of inquiry pertaining to financial information topics, such as long-term care insurance, and to community information issues such as housing information (Coyne, 1991; Silverstein et al., 1993).

Help received from hotline professionals was, across all categories, reported to be used to a large extent and was helpful to a large to very large extent. In previous studies of Alzheimer’s disease hotline callers, positive levels of satisfaction with the information and referrals were found in one study (Coyne, 1991), although in another study the helpfulness of the information provided was rated as positive for some domains (e.g. nursing home information) and as negative for others (e.g. financial issues) (Silverstein et al., 1993). In the current study, help in individual domains of inquiry (i.e. care, financial, institutional placement, and community) was rated on average as helpful, ranging from a moderate to a very large extent; ratings for usefulness were also positive except for that relating to institutional placement, which was rated small to moderate. Nevertheless, up to two months following the query, the issue prompting it remained unresolved in half of the cases.

To some extent, this low resolution rate may reflect unmet needs concerning information on nursing home-specific eligibility criteria and rights for such care, as well as subpopulation-specific information and referrals. Failure to provide more specific details on nursing homes may also help explain why callers were least likely to act on the institutional placement information provided. These informational needs can be addressed by enhancing hotline procedures. Specifically, the hotline can aim to provide personalized information with a high degree of specificity with regard to the information need at hand, such as eligibility criteria relating to a particular nursing home and to disease-specific (e.g. cancer) referrals. Considering the need of informal caregivers of older persons with chronic health conditions for individualized practical information (Washington et al., 2011), such improvements to hotline services are likely to benefit both older persons and their caregivers. But consideration needs to be given as to whether the hotline can provide this increase in services at its current level of funding and to whether any necessary increase in funding is likely to be obtained.

Other callers expressed a need for help in applying for services and in confronting the service providers. Hotline representatives claimed that as a hotline, they do not have the resources for handholding callers through the process of obtaining care, nor is it their mandate to do so. When available, they may be able to refer them to other services that may assist in this process. Monitoring the extent to which such needs are present would be a first step in elucidating avenues for addressing them. This is an important task for future research.

In analyzing unsolved problems, we differentiate between unsolved problems that could have possibly been solved by the hotline with some improvements, and problems that could not be solved in that way and are based on deeper societal problems that represent general unmet needs in Israeli society. These unmet needs include information, system, and financial needs (Table 2) and warrant wider systemic changes. For example, there is a need for a wider dissemination of knowledge about aging among senior citizens and caregivers. System unmet needs include quicker processing of requests submitted to care companies and for the appointment of legal guardians. Financial unmet needs that were identified suggest that particular laws may comprise an obstacle to provision of proper care, such as those establishing criteria for financial benefits and the Israeli law requiring children to pay for the care of their parents. These general unmet needs raise questions regarding the adequacy of national efforts aimed at maintaining the wellbeing of older persons in the Israeli society: Which subpopulations are overlooked in care-related laws in Israel? Should financial benefits criteria be reconsidered? What are the existing efforts for the dissemination of public knowledge on aging in Israel? Are they effective? Future studies aimed at increasing our understanding of these consequential questions are warranted.

In examining the utility of the hotline, the context of social services call centers (Coleman and Harris, 2008) can be instructive. The hotline described in the present article, however, may be more restricted in its aims than a call center, in that the hotline aims to provide information and referrals concerning services and rights but not to provide actual social services. Nevertheless, both hotlines and call centers share a reliance on phone calls as a method of communication as well as on information technology. Both lack a sense of place and locality that limits the ability to utilize local networks and resources. In both cases, there is no direct contact with consumers, and users often contact the hotline or call center as a last resort, usually when they are very distressed. The utility of services is limited by its lack of personal face-to-face contact, its limited aims as a service aimed at rapid response and resolution, and the lack of local connection, so that it may not be able to solve the original issue for a substantial proportion of users. Such service outcomes may indicate the need for a more encompassing service for cases where hotline services cannot provide adequate resolution.

In sum, the findings of the current study highlight the importance of a telephone hotline as a useful information resource for callers, as well as a resource for researchers to help elucidate the needs of older persons and barriers to their resolution. While the study is limited by a small sample, it illustrates the potential provided by follow-up inquiries, not only to ascertain satisfaction levels with hotline services but also to suggest avenues for service improvement both for the hotline itself, and even more so on a societal level. To our knowledge, this is the first study to utilize hotline inquiry data in order to describe system-level barriers to meeting the needs of older persons and caregivers. Due to the limited sample size, not all barriers may have been represented. This should be examined in future, larger, studies.

Footnotes

Acknowledgements

The authors would like to thank Anka Simovich for her help with the data collection.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

Jiska Cohen-Mansfield, PhD is a Professor at the Department of Health Promotion at the School of Public Health, and the director of the Minerva Center for Interdisciplinary Study of End of Life at Tel Aviv University, Tel Aviv, Israel. Her work involves mental health promotion for older persons.

Rotem Perach, MSc, is a former research assistant at the Herczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel. He is currently a PhD student at the University of Kent, Canterbury, UK.

Tali Kadmon-Stern is a gerontologist with an MA from Haifa University in Israel. She is the manager of ‘Reuth-Eshel’ Information Center, Tel Aviv, Israel.

Shulamit Albeck has a BA in Social Work and a PhD in Sociology. She has taught at Bar Ilan University and is currently a counselor to older persons and their families at the Reuth-Eshel information Center in Tel Aviv, Israel.

Dror Rotem is Director of planning, research and development at JDC-Eshel - the Organization for Planning and Development of Services for Older Persons in Israel.

Tamara Lynn Arnow has an MPH from the Mailman School of Public Health at Columbia University in New York. She contributed to this paper when she volunteered at the Herczeg Institute on Aging at Tel Aviv University, Tel Aviv, Israel.

Yaffa Lerman, MD is Director of the Geriatric Division, Tel Aviv Sourasky Medical Center in Tel-Aviv, Israel. She is a member of the National Committee of Geriatrics in Israel.

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