Long-term Care Options Research Articles

Valuation of guaranteed lifelong withdrawal benefit with the long-term care option

In this paper, under the stochastic interest rate framework, we consider the valuation of a Guaranteed Lifelong Withdrawal Benefit (GLWB) annuity product by explicitly incorporating the health state of the policyholder through the long-term care (LTC) option. The product provides policyholders with protection against longevity risk and market downturns, as well as financial support when facing LTC needs. Within the context of dynamic withdrawals, the valuation of the GLWB annuity with the LTC option is characterized as a stochastic optimal control problem. We introduce a novel bang-bang analysis approach without the usual convexity assumption in literature and prove that the optimal withdrawal strategies for the policyholder are constrained to a finite set. Furthermore, we perform a sensitivity analysis on the price determinants of GLWB annuities with and without the LTC option, and provide economic interpretations. Lastly, we investigate the impact of gender on the optimal withdrawal strategy and the fair fee of the annuity with the LTC option.

An exploratory look at perceptions of southern LGBT older adults on three long-term care services

As LGBT older adults continue to age, many will need some form of Long-Term Care (LTC). LTC allows the individual to live as independently and safely as possible. Because of the lack of social support systems for LGBT older adults, while aging, some LGBT individuals and organizations are concerned about future LTC. The study utilized a cross-sectional approach. Participants were 728 self-identified LGBT older adults who completed a survey on their perceptions of LTC services. The results of this study reveal that older LGBT adults view future LTC in three different ways: (1) Fear surrounding LTC, such as providers, staff, and other residents, (2) specific facilities of LTC including nursing homes and assisted living facilities, and (3) facilities of LTC that are non-clinical and deal with community or home care. To improve LTC services, the researchers recommend creating more LGBT-specific LTC options, hiring more LGBT providers, and implementing diversity training for providers and staff members. The study aims to update existing research on older LGBT adults and LTC. More quantitative and qualitative research is needed in all aspects of LGBT older adults, especially in LTC settings.

Disabled life expectancy among older Colombian men and women.

Colombia's population is rapidly aging and older adults are living longer, however, we have limited information on the level of disability and number of years older Colombians spend with disability. We estimated age-and-gender specific ADL, IADL and mobility disability prevalence and disabled life expectancy (DLE) and to examined gender differences. Life tables came from the Colombian vital statistics and disability prevalence data came from the cross-sectional 2015 Colombia National Survey of Health, Well-being, and Aging. Disabled life expectancy (DLE) was calculated using Sullivan's method. About one-third to one-half of remaining years will be spent with IADL or mobility disability. The remaining years of life spent with ADL was relatively low at younger ages, but by age 85, about half of remaining life will be spent with disability. Compared to men, women had higher levels of disability and are estimated to spend more years with disability. Gender differences in ADL did not emerge until ages 70 and older. Older Colombians, in particularly women, are estimated to live a significant proportion of their life with disability, particularly IADL and mobility disability. High levels of disability are concerning because the country lacks adequate infrastructure and has limited options for long term care.

IDENTIFYING EFFORTS AND CHALLENGES OF MARKETING THE DEPARTMENT OF VETERANS AFFAIRS MEDICAL FOSTER HOME PROGRAM

Abstract The United States (US) Department of Veterans Affairs (VA) Medical Foster Home (MFH) program is a long-term care (LTC) option for Veterans needing nursing home-level care. In the MFH program, Veterans live in the home of a community-based caregiver who has been recruited and screened by VA staff. Since 2016, VA Offices of Rural Health and Geriatrics and Extended Care has expanded the program, and by 2026 the VA plans to have programs at every VA Medical Center. To describe current efforts to market the MFH program, we conducted a national survey of MFH staff between Dec. 2, 2021-Jan. 6, 2022. We sent invitations via email, including a website link to the survey. N=94 completed the survey. Three team members analyzed open-ended data, using an inductive and deductive approach to thematic analysis. Findings revealed that external marketing strategies primarily focused on recruiting appropriate caregivers. Efforts included in-person presentations to community groups, utilizing local media outlets, manning booths at local health and job fairs, and providing written materials about the program. Internal marketing efforts included approaching many different VA departments including inpatient social workers, case managers, and discharge planners to identify Veterans for the program, and holding in-service presentations. Challenges included MFH coordinators having minimal time to market the program and receiving inconsistent support from the VA Public Affairs Office depending on location. Findings will inform expansion of the MFH program, which is paramount as the demand for LTC increases concurrently with the aging Veteran population.

Lost in transition? Community residential facility staff and stakeholder perspectives on previously incarcerated older adults’ transitions into long-term care

BackgroundEstablishing an effective continuum of care is a pivotal part of providing support for older populations. In contemporary practice; however, a subset of older adults experience delayed entry and/or are denied access to appropriate care. While previously incarcerated older adults often face barriers to accessing health care services to support community reintegration, there has been limited research on their transitions into long-term care. Exploring these transitions, we aim to highlight the challenges of securing long-term care services for previously incarcerated older adults and shed light on the contextual landscape that reinforces the inequitable care of marginalized older populations across the care continuum.MethodsWe performed a case study of a Community Residential Facility (CRF) for previously incarcerated older adults which leverages best practices in transitional care interventions. Semi-structured interviews were conducted with CRF staff and community stakeholders to determine the challenges and barriers of this population when reintegrating back into the community. A secondary thematic analysis was conducted to specifically examine the challenges of accessing long-term care. A code manual representing the project themes (e.g., access to care, long-term care, inequitable experiences) was tested and revised, following an iterative collaborative qualitative analysis (ICQA) process.ResultsThe findings indicate that previously incarcerated older adults experience delayed access and/or are denied entry into long-term care due to stigma and a culture of risk that overshadow the admissions process. These circumstances combined with few available long-term care options and the prominence of complex populations already in long-term care contribute to the inequitable access barriers of previously incarcerated older adults seeking entry into long-term care.ConclusionsWe emphasize the many strengths of utilizing transitional care interventions to support previously incarcerated older adults as they transition into long-term care including: 1) education & training, 2) advocacy, and 3) a shared responsibility of care. On the other hand, we underscore that more work is needed to redress the layered bureaucracy of long-term care admissions processes, the lack of long-term care options and the barriers imposed by restrictive long-term care eligibility criteria that sustain the inequitable care of marginalized older populations.

Long-Term Care Preferences and Sexual Orientation-A Systematic Review and Meta-Analysis.

The number of sexual and gender minority older adults who require long-term care is steadily increasing. The purpose of this systematic review and meta-analysis was to synthesize the evidence related to preference for long-term care with regard to sexual orientation and gender identity. Systematic review and meta-analysis. We searched PubMed/MEDLINE, Ovid/PsycINFO, and Web of Science from inception to July 2020 (updated in July 2021). Search terms embraced 3 themes (1) sexual and gender minorities, (2) long-term care, and (3) preferences. Quantitative studies of the adult population were included. Screening, data extraction, and quality assessment followed the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The proportions were pooled using meta-analysis and random effects models. A total of 17 articles were included out of 5944 studies of potential relevance. The perception of nursing homes (NHs) that emerges from these studies is predominantly negative for heterosexuals and lesbian, gay, bisexual and trans (LGBT) individuals (n= 11). Across 6 studies (10 outcomes), the pooled estimate for the proportion of individuals with a preference to move into a NH was 10.6% [95% confidence interval (CI) 7.88%‒13.22%, I2= 97.4%]; 13.7% (95% CI 8.6%‒18.7%) for LGBT individuals and 7.3% (95% CI 3.14%‒11.50%) for heterosexuals. LGBT-friendly NHs were preferred by between 55% and 98% of LGBT respondents. Informal care provided by partner or family was one of the preferred options (n= 6). It was preferred by 33% to 70% of various groups of LGBT respondents. The preference to move into a NH is relatively low among both heterosexuals and sexual and gender minority adults. Findings showed negligible differences in preferences to move into a NH between heterosexuals and sexual and gender minorities. LGBT-friendly long-term care facilities where every member feels welcomed and not discriminated against seem to be one of the favorable long-term care choices among LGBT individuals. This knowledge is important to inform nursing services and policy makers about the preferred long-term care options. Providing LGBT-friendly facilities is usually less expensive than providing care in newly created LGBT-only facilities.

DUALS AND ASSISTED LIVING: EXAMINING ACCESS AND OUTCOMES

Abstract Assisted living, a popular long-term care option for older adults needing personal care assistance, is increasingly serving a vulnerable population of low-income older adults dually-enrolled in Medicare and Medicaid (duals). However, we know very little about the needs of this population, their access to assisted living, the quality of care duals are receiving, and how this varies across states and assisted living providers. This symposium will include five presentations using national data and focused on access to assisted living for duals and the quality of care that duals in assisted living settings receive. The first two presentations take different approaches to investigate access to assisted living and how it relates to Medicaid policy: one examines Medicaid policies and their relationship to geographic access, and the other presents results from an analysis examining the association between Medicaid financing and segregation of duals. The next three presentations highlight important findings related to the quality of care for duals in assisted living: one focuses on concentration of duals in assisted living and its relationship with hospitalization and nursing home placement, one examines injury-related emergency department visits among duals, and the final presentation discusses the ability of duals in assisted living to age in place toward the end of life. The discussant, an expert in Medicaid policy, will conclude with a discussion of states’ different approaches for covering services in assisted living through their Medicaid programs, highlighting the opportunities for increasing equitable access and ensuring high quality care is delivered to this vulnerable population.

How Social Determinants of Health of Individuals Living or Working in U.S. Department of Veterans Affairs Home-Based Long-Term Care Programs in Puerto Rico Influenced Recovery after Hurricane Maria.

In September 2017, Hurricane Maria devastated Puerto Rico, causing extensive infrastructure damage and a significant number of deaths. In the months and years since, recovery from Maria has been slow, hampered by delayed delivery of fiscal aid, corruption, economic hardships, and Puerto Rico’s colonial status. Simultaneously, Puerto Rico’s population is rapidly aging and hundreds of thousands of mostly younger Puerto Ricans are migrating out of Puerto Rico for more opportunities. Many Puerto Ricans who are older or disabled and need long-term care receive this care in home-based environments, as Puerto Rico has minimal institutionalized long-term care infrastructure and limited funding to expand it. The Department of Veterans Affairs (VA) offers several home-based long-term care options for Veterans in Puerto Rico. In this qualitative case study, veterans, VA staff, veterans’ caregivers, caregivers’ family members, and veterans’ family members receiving or involved with providing this care were interviewed regarding their experiences during and after Hurricane Maria. Specifically, this study highlights how social determinants of health of those residing in or involved with VA home-based long-term care programs influenced recovery from Hurricane Maria, and how findings can inform disaster recovery and provision of home-based long-term care going forward.

Opportunities for transitional care and care continuity following hospital discharge of older people in three Nordic cities: A comparative study.

To outline and discuss care transitions and care continuity following hospital discharge of older people with complex care needs in three Nordic cities: Copenhagen, Tampere and Stockholm. Data on potential pathways following hospital discharge of older people were obtained from existing literature and expert consultations. The pathways for each system were outlined and presented in three figures. The hospital discharge process of the systems was then compared. In all three care systems, the main care path from hospital is to home. Short-term intermediate healthcare can be provided in all three systems, possibly creating additional care transitions; however, once home, extensive home healthcare may prevent further care transitions. Opportunities for continuity of care include needs assessments (all cities) and meetings with the patient about care upon return home (Copenhagen, Stockholm). Yet this is challenged by lack of transfer of information (Tampere) and patients' having to apply for some services themselves (Tampere, Stockholm). Comparisons of the discharge processes studied suggest that despite individual care planning and short- and long-term care options, transitional care and care continuity are challenged by limited access as some services need to be applied for by the older person themselves.

Products and Strategies for the Decumulation of Wealth during Retirement: Insights from the Literature

The question how individuals should (optimally) annuitize their wealth remains of high relevance in light of longevity risk and volatile capital markets. In this article, we first present traditional and innovative products and strategies for the decumulation of wealth during retirement, based on a review of 72 selected academic articles in peer-reviewed journals. We further identify relevant factors that generally influence the conception of these products from the retirees’ perspectives, and derive implications for product developers, before concluding with avenues of future research. Our results indicate that innovative suggestions often comprise tontine-like structures, exploit actuarial and accounting smoothing in various ways, defer annuitization to higher ages, or combine it with long-term care options, for instance. Key areas of future research in this field include the consideration of both insurer and retiree perspectives in the analysis of products, using behavioral considerations when evaluating the retirees’ perspective, and taking into account the impact of costs or expenses. While recent articles increasingly consider these aspects, manifold opportunities for future research remain.

Adult Day Service Use Among Minority Older Adults: Facilitators, Barriers, and Outcomes From an Updated Integrative Literature Review Between 2010 to 2021

Adult day services (ADS) are one of the more popular long-term care options for racial and ethnic minority older Americans. Focusing on minority older adults, this study aims to (a) identify both the individual and structural/organizational levels factors associated with ADS use and to (b) examine ADS' effect on health and well-being. Using the integrative review approach of Whittemore and Knafl, we found 14 studies published between 2010 to 2021. Findings concluded that individual-level needs and enabling factors were associated with ADS use and outcomes among minority older adults centered mostly on quality of life. Organizational/structural characteristics of ADS were never empirically examined in relation to service use or health outcomes. Future research should move beyond the individual level to identify and address the impact of the institutional structure, culture and practice on access, quality, and use.

Impact of COVID-19 on Structure and Function of Program of All-Inclusive Care for the Elderly (PACE) Sites in North Carolina.

ObjectivesThe novel coronavirus disease 2019 (COVID-19) deeply affected all forms of long-term care for older adults, highlighting infection control issues, provider and staff shortages, and other challenges. As a comparatively new, community-based long-term care option, the Program of All-Inclusive Care for the Elderly (PACE) faced unique challenges. This project investigated the impact of COVID-19 on operations in all PACE programs in one US state.DesignQualitative study.Setting and ParticipantsStructured interviews with administrators of all 12 PACE programs in North Carolina.MethodsInterviews were conducted December 2020 to January 2021 by trained interviewers over Zoom; they were transcribed, coded, and qualitatively analyzed using thematic analysis.ResultsReported COVID-19 infection rates among PACE participants for 2020 averaged 12.3 cases, 4.6 hospitalizations, and 1.9 deaths per 100 enrollees. Six themes emerged from analyses: new, unprecedented administrative challenges; insufficient access to and integration with other health care providers; reevaluation of the core PACE model, resulting in a transition to home-based care; reorientation to be more family-focused in care provision; implementation of new, creative strategies to address participant and family psychological and social well-being in the home; and major reconfiguration of staffing, including transitions to new and different roles and a concomitant effort to provide support and relief to staff.Conclusions and ImplicationsWhile facing many challenges that required major changes in care provision, PACE was successful in mounting a COVID-19 response that upheld safety, promoted the physical and mental well-being of participants, and responded to the needs of family caregivers. Administrators felt that, after the pandemic, the PACE service model is likely to remain more home-based and less reliant on the day center than in the past. As a result, PACE may have changed for the better and be well-positioned to play an expanded role in our evolving long-term care system.

Designing for Plurality in Democracy by Building Reflexivity

Designing for Plurality in Democracy by Building Reflexivity

Aligning quality improvement efforts and policy goals in a national integrated health system.

To describe the design and impact of a systematic, enterprise-wide process for engaging US Department of Veterans Affairs (VA) leadership in prioritizing scarce implementation and evaluation resources. From 2017 to 2021, the VA Quality Enhancement Research Initiative (QUERI) identified priorities from local, regional, and national leaders through qualitative discussions and a national survey and tracked impacts via reports generated from competitively funded initiatives addressing these priorities. Guided by the Learning Health System framework and QUERI Implementation Roadmap, QUERI engaged stakeholders to nominate and rank-order priorities, peer-reviewed and funded initiatives to scale up and spread evidence-based practices (EBPs) using theory-based implementation strategies, and evaluated the impact of these initiatives using the QUERI Impact Framework. QUERI collected priority nominations through qualitative discussions and a web-based survey, and live voting was used to rank-order priorities. QUERI-funded teams regularly submitted progress reports describing the key activities, findings, and impacts of the quality improvement (QI) initiatives using a standardized form created in the VA Research Electronic Data Capture (REDCap). QUERI launched five QI initiatives to address priorities selected by VA leadership. In partnership with 28 health system leaders, these initiatives are implementing 10 EBPs across 53 sites, supporting 1055 VA employees in delivering evidence-based care. The success of these initiatives led to an expansion of QUERI's process to address 2021 VA leadership priorities: virtual care, health disparities, delayed or suppressed care due to COVID-19, employee burnout, long-term and home care options, and quality and cost of community care. QUERI, a unique program embedded in a national integrated health system, deployed a novel approach to inform policy making and enhance the real-world impact of research through prioritization of limited resources, rigorous peer-review, and assessment of impacts on the health system, employees, and Veterans.

Implementation and dissemination of home and community-based interventions for informal caregivers of people living with dementia: a systematic scoping review protocol

IntroductionAgeing in place, supported by formal home and community services and informal caregivers, is the most used long-term care option for people with dementia (PwD). Informal caregivers are inundated by...

Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility.

Assisted Living (AL) has become an important residential long-term care option in the United States, yet very little is known about the nature and quality of care received in this setting by racial/ethnic minorities or residents dually eligible for Medicare and Medicaid. Using calendar year 2018 Medicare data, we identified 255,564 fee-for-service Medicare beneficiaries age 55+ who resided in 24,108 ALs across the United States. We fit several logistic regression models with individual-level covariates and AL-level fixed effects, to examine the association between race/ethnicity and dual status with inpatient hospital admission, 30-day readmission, emergency room use, and nursing home placement. Significant variations in these measures were found both within and across ALs for racial/ethnic minority and dual residents. Our results suggest that disparities in outcomes are most significant by dual eligibility status rather than by race/ethnicity alone. These findings provide important implications for providers, policy makers, and researchers.

Valuation of long-term care options embedded in life annuities

AbstractIn most industrialised countries, one of the major societal challenges is the demographic change coming along with the ageing of the population. The increasing life expectancy observed over the last decades underlines the importance to find ways to appropriately cover the financial needs of the elderly. A particular issue arises in the area of health, where sufficient care must be provided to a growing number of dependent elderly in need of long-term care (LTC) services. In many markets, the offering of life insurance products incorporating care options and LTC insurance products is generally scarce. In our research, we therefore examine a life annuity product with an embedded care option potentially providing additional financial support to dependent persons. To evaluate the care option, we determine the minimum price that the annuity provider requires and the policyholder’s willingness to pay for the care option. For the latter, we employ individual utility functions taking account of the policyholder’s condition. We base our numerical study on recently developed transition probability data from Switzerland. Our findings give new and realistic insights into the nature and the utility of life annuity products proposing an embedded care option for tackling the financing of LTC needs.

Long-Term Care Options in Florida: Their Availability by County Demographics.

Older people express a preference for home and community-based care over skilled nursing, realizing that preference, however, is dependent upon having those options available. The present exploratory study uses publicly available data to understand if the geographic availability of long-term care options-skilled nursing, assisted living, home health, and homemaker/companion services-are equally distributed by demographics in Florida. Regression analyses showed that the percent 65 and older and the percent in poverty in a county were not related to long-term care availability or quality. Findings indicate that Hispanic older people have less access to nursing home beds, greater access to home health and homemaker/companion agencies, and tend to live in counties with a greater number of assisted living facility (ALF) deficiencies while Black older people have greater access to homemaker services. Rural counties had lower rates of home health and homemaker/companion agencies and fewer ALF deficiencies. The 65 and older population would benefit from the increased availability of long-term care options near the communities in which they live.

Cultural Differences in the Intended Use of Long-Term Care Services in the United States: The Role of Family Ties.

In the light of an increasingly diverse older population in the United States, there is an ongoing discussion on how cultural factors contribute to individual long-term care (LTC) needs and service use. This study empirically assesses whether the level of acculturation and cultural differences in the importance of the family shape foreign-born immigrants' intention to use certain LTC services. We correlated immigrants' intention to use certain LTC services to the cultural strength of family ties that prevails in their region of origin. We used data from the National Health Interview Survey and the World Values Survey/European Values Study for analysis. Multinomial logit models were estimated and predisposing, enabling, and need factors were controlled for. Estimations were weighted to account for the sampling structure, and sensitivity analyses were conducted. Immigrants from cultures with stronger family ties are significantly more likely to intend the use of LTC options that include the family. Furthermore, immigrants are less likely to intend the use of exclusively family care when having lived in the United States for a longer time. We conclude that cultural differences in family ties shape immigrants' intention to use certain LTC services. If policymakers aim at increasing the provision of specific LTC services or support to family caregivers, there should be a careful evaluation of demand-side factors in an increasingly culturally diverse society.

Long-Term Care Expectations and Plans of Transgender and Nonbinary Older Adults.

Transgender and nonbinary (TNB) older adults endure discrimination from medical providers and expect it in institutional long-term care. Gender identity-based discrimination is connected to negative health outcomes and reluctance to access needed care. The aim of this study is to explore how gender identity affects TNB older adults' fears, hopes, and plans for use of institutional long-term care. Co-investigators conducted semi-structured interviews with 24 TNB older adults in Minnesota, collaboratively analyzed the results using reflexive thematic analysis, and member-checked emergent themes. Oppression is central to participants' consideration of future long-term care. They fear mistreatment and loss of authentic gender expression and recognition in long-term care facilities. Fears of oppression factor into consideration of suicide and physical transition, although some participants hope societal shifts will lead to unbiased long-term care. Creation of anti-oppressive institutional and community-based long-term care options is critical to effectively serve TNB people as they age into dependence.