Family caregivers of older adults frequently experience feelings of burden and depression though they may not come to the attention to health and service providers until they are at a point of crisis. Through a simple screening tool, the Maine Primary Partners in Caring (MPPC) project identified individuals providing care to older adults through rural primary care practices, in order to provide upstream interventions before caregivers were in crisis. This paper describes a sample (n=62) of rural family caregivers identified through their physicians' offices. High levels of caregiver burden and depression were reported. Family support and knowledge of caregiver tasks predicted decreased caregiver burden and depression, while isolation predicted increased caregiver burden. Implications of these results for gerontological social workers are outlined.

The Balanced Budget Act of 1997 dramatically decreased reimbursements for traditional Medicare home health patients. A multivariate analysis of Medicare Current Beneficiary Survey data showed that African American and "other" users experienced greater decreases in home care between 1996 and 1998 than did White users. These results suggest (a) race/ethnicity is an independent factor in determining service use post-BBA and (b) health policy has a disparate impact on minority older adults. Capitated payment systems must be pursued cautiously to avoid negative effects on vulnerable populations. The potential for current and future Medicare policy changes to negatively affect vulnerable populations is also discussed.

An alternative frame of reference for geriatric practice is presented centering on the concept of productive ageing. This perspective underscores two distinct but compatible conceptualizations of the ageing experience: l) an external, utilitarian view that emphasizes concrete societal contributions made by older adults to others whether they be individuals, families, groups, organizations, or communities; and 2) an internal, affective view which emphasizes the older person subscribing to personal philosophies positively impacting one's own well-being and quality of life. Both emphasize engagement by older adults in the economic, social, and physical environment as well as the importance of elders having direction, structure, purpose in life, engaged in activity, and accomplishing tasks. Assets, resources, capacities, and skills of older adults are underscored rather than problems, deficiencies, and needs. A productive ageing paradigm is seen to transcend the physical or functional status of the older person and have direct implications for health and human service personnel assuming an expanded set of professional functions in both traditional and nontraditional community service settings.There is value in stepping back, if only temporarily, from the daily professional tasks of working with the physically and mentally frail older person, addressing the problems and losses of ageing, and treating ageing-related disease and incapacity. Health and human service professionals can benefit from becoming familiar with the changing demographics of old age, including impressive improvements being registered in terms of financial, physical, and social well-being in later life. An Alternative Frame of ReferenceThere is a broader flame of reference to be considered for geriatric practice. It focuses on a new and expanded set of professional functions that prac-

Results are presented from a study that examined the relationship between gender orientation and the unique stresses and gratifications for men who are engaged in caregiving tasks traditionally performed by women. The men report having found emotional gratification an important motivating factor, and they tended to ascribe to themselves many affective traits usually associated with the female role.

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This study examines the policies and procedures that home health care agencies have developed to handle the incapacitated patient and life-sustaining treatment decisions. Data collected from a survey of 154 home health care agency directors and interviews with 92 local agency staff (including nurses and social workers) and 67 patients confirmed that directors, staff, and patients agree that patients are informed about their legal rights. When asked about specific rights, fewer patients were aware of their right to execute an advance directive, and even fewer patients had actually executed one. Only 67 percent of agencies reported having existing policies on advance directives and life-sustaining treatment decisions, whereas 41.5 percent had policies on how to handle the patient with questionable decision-making capacity. Consistent policies are needed for social workers, nurses, and other staff to handle such difficult ethical dilemmas. A review of specific agency policies is presented with recommendations for future policy changes and development.

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