Long-term Services And Supports Research Articles

Tracking long-term services and supports rebalancing through workforce data.

To understand trends in the long-term services and supports (LTSS) workforce and assess workforce data as a measure of progress in shifting LTSS resources from institutional to community-based settings. Workforce data from the American Community Survey from 2008 to 2022. Measures of LTSS rebalancing and institutional and community workforce supply per 1000 persons with LTSS needs were constructed. After showing national trends over the study period, state fixed effects regressions were used to evaluate the within-state relationship of these measures with existing measures of LTSS utilization. Workforce supply measures were compared to the percentage of state Medicaid LTSS spending spent in the community to assess their utility for across state comparisons. Each state's progress in LTSS rebalancing over the study period was then shown using workforce data. A sample of 336,316 LTSS workers and 3,015,284 people with LTSS needs over the study period was derived from American Community Survey data. From 2008 to 2022, the percentage of the LTSS workforce employed in the community rose from 44% to 58%. Thirty states saw more than a 10 percentage point increase. From 2008 to 2013, the size of the community workforce expanded dramatically but has since stagnated. In contrast, the institutional workforce entered a long-term decline beginning in 2015 that accelerated during the COVID-19 pandemic. State fixed effects regressions showed that measures of workforce supply have a strong relationship with LTSS utilization measures for older adults, but not for younger people with disabilities. Workforce data can serve as an effective measure of changes in LTSS utilization for older adults. This offers researchers and policymakers a useful alternative to administrative claims, bypassing threats to comparability from coding changes and the shift to managed care. Additional data is needed on workforce trends in services for younger LTSS consumers.

Higher levels of state funding for Home- and Community-Based Services linked to better state performances in Long-Term Services and Supports.

To examine the relationship between the level of state funding for Home- and Community-Based Services (HCBS) and state overall and dimension-specific performances in Long-Term Services and Supports (LTSS). We employed state-level secondary data from the Medicaid LTSS Annual Expenditures Reports, the American Association of Retired Persons (AARP) State Scorecards, the U.S. Census, and Federal Reserve Economic data, spanning the timeframe of 2010-2020. Overall state LTSS rankings, along with dimension-specific rankings, were modeled separately against state Medicaid spending on HCBS relative to total Medicaid spending on LTSS. All models were adjusted for state covariates, secular trend, and state fixed effects. The study sample included all 50 states and the District of Columbia. However, California, Delaware, Illinois, and Virginia were excluded from FY2019 due to missing data on Medicaid HCBS expenditures. Every 10 percentage-point increase in the proportion of Medicaid LTSS spending to HCBS demonstrated 2.05 points improvement (95% confidence interval [CI]: -3.88 to 0.22, p = 0.03) in rankings for state overall LTSS system performance, 2.92 points improvement (95% CI: -4.87 to 0.98, p < 0.01) in rankings for the Choice of Setting and Provider dimension, as well as 1.73 points (95% CI: -3.14 to 0.32, p = 0.02) ranking improvement in the dimension of Effective Transitions. Our study suggested promising effects of increased state funding for HCBS on LTSS performance.

RACE/ETHNICITY DISPARITY FOR PEOPLE WITH LTSS NEEDS IN CALIFORNIA: DISABILITY, FINANCE, AND HEALTH AND WELL-BEING

Abstract Older adults and people with disabilities have high needs for Long-Term Services and Supports (LTSS). Disability status, financial difficulties, and health and well-being are likely not uniformly experienced by all people with LTSS needs. Subgroups of older adults and people with disabilities, such as racial/ethnic minorities, may be at significant risk of experiencing financial difficulties and stress about making ends meet. This study used the first cycle of data (2019-2020) from the California Long-Term Services and Supports (CA-LTSS) survey, merged with select data from the California Health Interview Survey (CHIS) (N = 2,030). Multivariate Regressions and Conditional Process Analysis (CPA) were applied to test the hypothesized relationships. Findings show that black/African American and Asian participants with LTSS needs were more likely to have cognitive impairments. Black/African American participants with LTSS needs were more likely to report difficulties in activities of daily living. Racial/ethnic minorities with LTSS needs experienced diverse and more financial difficulties on average than their white counterparts. Asian participants with LTSS needs reported worse psychological distress than other racial/ethnic groups. American Indians and Alaska Natives with cognitive impairments were more likely to have more financial difficulties, and those with difficulty in instrumental activities of daily living were more likely to report worse self-rated health. This study moves beyond the typical white/black disparities analyses and focuses on diverse racial/ethnic groups. We need to address the financial needs of various racial/ethnic groups of people with LTSS needs and target policies and service programs to meet their mental health needs.

CONTEXTUAL FACTORS IN AGING AND LONG-TERM SERVICES AND SUPPORTS RESEARCH

Abstract In the coming years, there will be more older Americans living in the community with extensive medical and long-term care needs increasing the need for long-term services and supports (LTSS) that assist with routine daily activities (e.g., bathing, dressing, medication management). Increasingly research studies are examining factors associated with receipt of LTSS including care preference, family availability and financial resources. Yet LTSS care experiences are likely a result of factors that extend beyond personal preference or individual factors, such as neighborhood quality. availability of home care workers, and state policy characteristics (e.g., state Medicaid generosity). Little research to date has examined how the LTSS environmental context affects the health and well-being of older adults with disabilities and their caregivers. In order to improve LTSS research we need to expand analyses to consider relevant contextual factors. This symposium will feature five presentations that provide novel insight regarding social and physical contextual factors contributing to LTSS using multiple data sources. We will describe (1) a conceptual framework of LTSS-relevant environmental domains and associations between select LTSS-relevant characteristics and older adult care experiences, (2) the relationship between neighborhood deprivation and place of death, (3) care experiences of older Medicare-Medicaid enrollees living in counties with Medicaid Managed Long-Term Services and Supports, (4) trends in paid home care employment and state public financing, and (5) associations between adverse consequences due to unmet, LTSS use, and social isolation.

CHARACTERISTICS AND CARE EXPERIENCES OF OLDER DUAL-ENROLLEES LIVING IN AREAS WITH MEDICAID MANAGED LTSS

Abstract Medicaid-funded long-term services and supports (LTSS) are foundational in helping older dual-enrollees with disabilities remain in the community. Over the past decade, nearly half of U.S. states have transformed LTSS delivery through managed LTSS (MLTSS) with the goal of improving care coordination and avoiding unnecessary health care utilization. Despite this rapid growth, no prior studies describe whether characteristics and care experiences of older dual-enrollees differ between counties with and without MLTSS. We draw on the nationally representative 2015 National Health and Aging Trends Study (NHATS) linked to the census tract of participants’ place of residence to examine differences in demographic characteristics, health, and care experiences of older dual-enrollees with LTSS need (n=462) by county-level presence of MLTSS. We broadly defined LTSS need as receiving assistance with one or more self-care or mobility activity or having probable dementia. More than half (56.9%) of older dual-enrollees with LTSS need lived in counties with MLTSS. Hispanic/other individuals were three times more likely to live in counties with (versus without) MLTSS presence (54.2% vs. 15.8%, p&amp;lt;0.0001) while individuals living in rural regions less likely to live in counties with MLTSS presence (8.8% vs. 31.8%, p&amp;lt;0.05). There were no differences in age, gender, self-reported health, dementia status, or number of chronic conditions of the sample population by MLTSS presence. Similarly, no differences were observed in experiencing adverse consequences from unmet care needs or social participation restrictions by MLTSS presence. These results are a foundational step toward building evidence and understanding who MLTSS programs are serving.

PRO-HOME: AN IMPLEMENTATION SCIENCE FRAMEWORK FOR MULTILEVEL BARRIERS AND FACILITATORS IN LTSS

Abstract Promoting Seniors’ Health with Home Care Aides (Pro-Home) is a randomized controlled trial (RCT) of a gentle physical activity program for frail older adults conducted in a community-based long-term services and supports (LTSS) delivery setting. Pro-Home is a hybrid effectiveness-implementation study, which aims to examine (1) the effectiveness of the program delivered by home care aides (HCAs) in maintaining physical function in older homecare recipients, and (2) how the intervention works in a real-world Medicaid-funded LTSS system. This paper describes barriers and facilitators that have long existed or evolved during the Pro-Home development, using quantitative/qualitative data from the mixed-method study informed by an implementation science framework. Facilitators include the knowledge and partnerships that resulted from multiple preliminary studies that illuminated HCAs’ work/life-related stressors, coping resources, and underutilized capacity and motivation to promote the health of clients and HCAs themselves in the context of the LTSS system. Another facilitator has been the physical activity program developed in another state’s LTSS service setting (not in an academic setting). The program was easy to learn and adapt into a program to be delivered by HCAs (as opposed to care managers). Barriers included turbulent LTSS environments (e.g., rapidly growing managed care presence, COVID-19). Those barriers have been addressed through partnership with stakeholders at multiple levels. Having completed the intervention and data collection phases, we found the project’s planning and implementation challenging but rewarding. Pro-Home has produced rich information that will have many implications for research, practice, and LTSS services delivery and financing systems.

SOCIAL ISOLATION, UNMET NEEDS, AND LONG-TERM SERVICES AND SUPPORTS IN COMMUNITY-DWELLING OLDER ADULTS

Abstract Social isolation is associated with adverse health outcomes among older adults but can be attenuated through increased social contact and support. Long-term services and supports (LTSS) are a potential mechanism to increase social contact and provide socially isolated older adults with the help needed to perform routine activities. Using a nationally representative sample of 6,705 community-dwelling older adults from the 2015 National Health and Aging Trends Study (NHATS), we examined associations between social isolation, functional difficulty, adverse consequences due to unmet needs, and indicators of the LTSS environment (e.g., Meals on Wheels). About 22% of older adults were socially isolated. Socially isolated older adults had greater functional difficulty compared to those who were not socially isolated (45.3% vs 38.3%; p&amp;lt;0.0001). Socially isolated older adults were more likely to be Medicaid enrollees (17.5% vs 8.4%; p&amp;lt;0.0001) and use LTSS including SNAP benefits (12.7% vs 5.5%; p&amp;lt;0.0001), Meals on Wheels (4.1% vs 1.6%; p&amp;lt;0.0001), energy/gas financial assistance (7.5% vs 4.2%; p&amp;lt;0.0001), and transportation services for older adults or people with disabilities (4.6% vs 2.7%; p=0.001). Despite greater LTSS use, socially isolated older adults more often experienced adverse consequences due to unmet needs compared to those who were not socially isolated (12.5% vs 7.7%; p&amp;lt;0.0001). Findings suggest that LTSS in the form of social and senior services are critical in supporting those lacking social connection, but they may not be adequate to support aging in place in the absence of informal support.

A POLICY COMPARISON OF THE EVOLUTION OF COMMUNITY-BASED LONG-TERM CARE POLICY BETWEEN TAIWAN AND THE UNITED STATES

Abstract Governments globally have been facing pressure to develop and implement effective policies to support population aging. This approach was historically rooted in a perception that as we age we become increasingly incapacitated. This research seeks to understand how policies in two countries valuing unpaid care differently, developed and implemented Long-term services and supports (LTSS). We compare the federal level efforts of implementing LTSS within the United States (U.S.) and Taiwan. Relying on a pre-established comparative framework developed by Richard Rose, we utilized a deductive analytical approach to assess the differences in policy options and timelines across Taiwan and the U.S.. After attending this session, participants will develop a deeper understanding of how Taiwan and the U.S. are working to offer home and community-based long-term care services. It wasn’t until the 1980s for the U.S. and late 1990s for Taiwan that LTSS were introduced with the intention of supporting people to live as independently as possible in their own homes for as long as possible (e.g., Department of Health and Human Services, 3-year Care Service Development Plan). It is likely that the delay in LTSS delivery between the two countries is rooted in the role that unpaid support is expected to play. There is increasing evidence that countries are shifting their policy efforts to focus less on aging as a social dependency and more on policies that encourage healthy longevity.

IMPROVING LONG-TERM CARE THROUGH GERIATRICS EDUCATION: A DEEP DIVE INTO GWEP AND GACA INITIATIVES

Abstract Formal geriatrics education remains limited for many of the numerous health care professionals working with older adults. A well-prepared long-term services and supports (LTSS) workforce is imperative to care for older adults with multiple chronic conditions, especially dementia. This study highlights the role of Geriatric Workforce Enhancement Programs (GWEPs) and Geriatrics Academic Career Awards (GACAs) in addressing this need. An online survey, conducted 5/2023-6/2023, captured data from GWEPs (n=18) and GACAs (n=11) about training offered towards age- and dementia-friendly care in LTSS settings. Results revealed that 13 GWEPS or GACAs provided 36 learning activities that addressed the first recommendation, “Delivering comprehensive, person-centered, equitable care that ensures residents’ health, quality of life and safety” of the National Imperative to Improve Nursing Home Quality (NASEM). Twelve GWEPS/GACAs provided 42 learning activities addressing the second NASEM report recommendation, “ensuring a well-prepared, empowered, and appropriately compensated workforce.” GWEPS/GACAs are also aiding LTSS settings in achieving Age-Friendly Health Systems Designations: one each supported level 1 or 2 designation, two supported achieving both levels. Additionally, four GWEP/GACAs are working with LTSS entities toward level 1 status, one toward level 2, and one toward achieving both levels. Our findings underscore the pivotal role of GWEPS/GACAs in enhancing geriatrics education, addressing challenges in LTSS, and the pressing need for continued support. Recommendations emphasize strengthening partnerships between LTSS settings and GWEPs/GACAs to bridge educational gaps. Implications indicate GWEPS and GACAs are playing a crucial role in helping LTSS settings achieve age-friendly standards and align with the NASEM report’s vision.

PROVIDERS AND DIRECT CARE WORKERS’ PERCEPTIONS OF RETENTION

Abstract Direct care worker (DCW) retention remains a persistent challenge for long-term services and supports (LTSS). Multiple studies have identified key factors for worker retention, including worker training and empowerment, career advancement opportunities, compensation, and communication. However, few studies include multiple perspectives on understanding work culture from both providers and DCWs, which is essential for developing effective retention strategies that address the needs and concerns of different stakeholders. This qualitative study explores elements of work culture through semi-structured in-depth interviews with 21 providers and 16 DCWs from 12 high-performing LTSS facilities and agencies across Ohio. The facilities/agencies were selected based on state-level family satisfaction and staff retention data. Three major elements of work culture emerged as important for DCW retention: 1) a family-like approach, 2) working conditions, and 3) worker empowerment. DCWs value a family-like approach in the workplace, which included relationships with clients and their supervisors. Favorable working conditions comprised freedom of choice, participative leadership, and effective communication that promoted retention. DCWs experienced empowerment through recognition and appreciation, coupled with financial incentives and career advancement opportunities. These findings suggest simple modifiable changes to work culture that improve worker retention in LTSS. This study urges policymakers to consider these implications for addressing the ongoing challenge of DCW retention.

BRIDGING RESEARCH TO PRACTICE: PRO-HOME EMPOWERS CARE PARTNERS TO PROMOTE EXERCISE IN HOME CARE

Abstract Regular physical activity (PA) benefits people of all ages. Mounting scientific evidence shows PA’s health benefits in older persons with chronic conditions. However, there remains a large research-to-practice gap in PA, especially in long-term services and supports (LTSS). Older adults who need help with basic daily activities, such as walking or standing, continue to face barriers at multiple levels of LTSS to become and remain physically active. This symposium will address the much-debated research-to-practice gaps, focusing on frail community-dwelling older adults in the context of a NIA-funded clinical trial. “Promoting Seniors’ Health with Home Care Aides (Pro-Home)” tests the effectiveness of a gentle, low-intensity PA program delivered by home care aides (HCAs) for community-dwelling older adults with nursing-home eligible care needs in real-world home care settings. Pro-Home is innovative because it empowers direct care workers (HCAs) with an easy-to-learn toolkit to deliver the program and keep their older clients motivated. The symposium starts with an overview of Pro-Home (Muramatsu), barriers and facilitators of Pro-Home at multiple levels of the LTSS system (Cruz Madrid), followed by Pro-Home’s critical elements: of research and practice: client-HCA dyad relationships and partnerships with stakeholders (Hu), in-home assessment of motor function in frail older adults (Yin), and inter-professional co-learning (Skowronski). The symposium concludes with a dialogue with the audience to identify actionable policy and practice strategies for building research-to-practice and practice-to-research bridges to build health promotion into LTSS to promote the well-being of older adults with disabilities and their care partners.

AARP PUBLIC POLICY INSTITUTE PRESENTS THE LONG-TERM SERVICES AND SUPPORTS STATE SCORECARD, 2023

Abstract This symposium will present and explore in-depth the 2023 Long-Term Services and Supports (LTSS) State Scorecard. With funding from The SCAN Foundation, The Commonwealth Fund, and The John A. Hartford Foundation, this Scorecard is the fifth edition from the AARP Public Policy Institute. The Scorecard ranks states across five key dimensions that comprise a framework for high-performing LTSS system performance: affordability and access, choice of setting and provider, quality and safety, support for family caregivers, and community and integration. In this symposium, speakers will discuss the Scorecard’s history, its most recent findings, and the implications of the COVID-19 pandemic for state LTSS system performance. In addition, the Scorecard explores LTSS equity, and we will discuss how policymakers, practitioners, the private sector, and other actors can further realize equitable systems of supports.

INTERPROFESSIONAL CO-LEARNING AT MULTIPLE LEVELS OF LTSS: PRO-HOME PROGRAMS AND RESEARCH

Abstract Promoting Seniors’ Health with Home Care Aides (Pro-Home), a randomized controlled trial (RCT) of a gentle physical activity program delivered by home care aides (HCAs) for their older clients in English or Spanish, provided unprecedented opportunities for collaboration and co-learning across multiple disciplines and professions (public health, health services research, sociology, medicine, physical/occupational therapy, kinesiology, social work, psychology, economics, medicine, nursing; frontline care workers, leaders and staff members of state and home care agencies, , social service agencies, researchers, undergraduate and graduate students). The turbulent long-term services and supports (LTSS) environment, which culminated in the COVID-19 pandemic, provided the study participants (HCAs and their older clients), multiple levels of LTSS stakeholders and the research team with rapidly evolving new contexts for the RCT. This paper presents how the Pro-Home project developed into a learning organization where individuals and organizations learn from each other to pivot at every new turn in the environment, focusing on the development of a novel interactive training for HCAs in-person or remotely. The initial training activities were conducted in-person. After adapting the material for remote delivery, we provided the latter sessions via phone with digital and physical tools. For each training session, we assessed outcome quality using an exit survey and other methods capturing HCAs’ program delivery. The presentation concludes with implications for research and practice in LTSS.

LGBTQ AGING PARADOX: NEEDING WHILE AVOIDING LONG-TERM SERVICES AND SUPPORTS

Abstract A growing body of literature recognizes the significant health disparities experienced by sexual and gender minority (SGM) older adults including higher rates of chronic conditions, mental illness, and disabilities in comparison to their peers. Simultaneously SGM older adults are more likely to age alone and not have a friend or family caregiver to provide support. At the same time SGM older adults express hesitation and fear in accessing formal long term services and supports (LTSS). One study of trans older adults noted that suicide was a preferred option to a nursing home. This paper will outline a complex paradox: Many SGM older adults (1) experience significant health disparities which may require additional support; (2) lack informal support thus needing to rely on formal LTSS; and (3) avoid formal services due in large part to fear of discrimination and poor treatment. Opportunities to mitigate the paradox through education and awareness as well as implications for policy and research will be discussed.

MEDICAID ADULT DAY SERVICE CENTERS STAFFING AND SERVICE DIFFERENCES BY PROFIT STATUS

Abstract Adult day service centers (ADSC) encompass a broad range of services, yet few studies have examined staffing and service differences in for-profit and non-profit centers. Previous long-term services and supports (LTSS) research has found that for-profit nursing homes have lower levels of staffing, however, this research has not extended to ADSCs. Data from the 2018 wave of the National Post-Acute and Long-Term Care Study were used to examine differences in staff hours per patient day (HPPD) and services offered in ADSCs by profit status. Only ADSCs that accept Medicaid were included because the majority of the responding ADSCs accept Medicaid (76.8%) and Medicaid acceptance and profit status are significantly related (p&amp;lt;.001). Using t-tests, there was a significant difference (p=.002) in total HPPD with higher HPPD in non-profit ADSCs, with a difference of about 13 minutes. Additionally, there were significant differences in the number of transportation (p&amp;lt;.001) and medical (p&amp;lt;.001) services offered by profit status, with for-profit ADSCs offering a higher number of services, although there was no difference in the number of social/behavioral services (p=.122). These findings suggest that ADSCs that accept Medicaid may be subject to similar incentive structures that lead to lower levels of staffing in for-profit LTSS. The higher number of transportation and medical services in for-profit ADSCs that accept Medicaid also suggests different financial models for for-profit and non-profit ADSCs. Future research should more closely examine factors associated with ADSC staffing levels and service provision, and how these measures are associated with quality of care.

PROJECTION OF MEDICAID SPENDING ON PEOPLE WITH ALZHEIMER’S DISEASE AND OTHER RELATED DEMENTIAS

Abstract As the US population is aging, the number of people with Alzheimer’s Disease and Other Related Dementias (ADRD) is increasing. People with ADRD have high expenditures on medical care and long-term services and supports (LTSS). Medicaid is the largest single payor for LTSS, however, the literature on the demographic trends and epidemiology of people with ADRD does not offer projections of Medicaid spending. The goal of this study was to develop an estimate for future Medicaid spending for people with ADRD for the state of Pennsylvania. The approach taken was to develop a demographic projection of the size of the older population, then estimate the fraction of people with ADRD who are eligible for Medicaid. Next, we used estimates of current spending trends to project future spending through 2025. Nearly all Medicaid participants with ADRD are dually eligible for both Medicaid and Medicare, however, Medicare managed care encounter data were not available for analysis. Thus, the prevalence of ADRD was constructed using Medicaid and Medicare fee-for-service (FFS) claims data. Two alternate estimates of the prevalence of ADRD among Medicare managed care enrollees were used (same as Medicare FFS, or slightly lower). Estimates were generated under several growth rates in per person spending on home and community-based services (HCBS). The results shows that growth in HCBS spending is the largest factor in predicting spending, leading to estimates ranging from $2.8 billion to $3.5 billion. Future research will extend the model to additional years.

BEYOND REDLINING: LAW, PROPERTY VALUES, RACIAL INEQUITIES, AND LTSS

Abstract This presentation will provide background regarding the social construction of property values and the interactive role that public and private institutions have played in creating racial disparities in property values. I will discuss known and proposed mechanisms through which this form of structural racism affects access to long-term services and supports (LTSS) and implications for the health of older adults and their care partners, presenting a specific example from my own research, which found that assisted living communities are located in 30% of communities in America. However, among communities with the highest percent Black population in their county, 31% of those located in counties with a low gap in Black-White economic mobility had access to assisted living, while less than 15% of those located within a county with a high Black-White gap in economic mobility had such access. I will describe how policymakers can use law to address racial disparities in geographic access by developing policies that 1) provide financial incentives for private investors to develop assisted living and other forms of LTSS in neighborhoods that otherwise wouldn’t see development due to low property values; 2) prioritize the location of new buildings in historically marginalized communities; 3) implement anti-displacement measures; 4) incorporate community input and engagement; and 5) ensure accessibility and affordability. Finally, I will describe how policymakers may consider the various actors and institutions that shape the housing market and how they interact with each other to produce outcomes that may reinforce or challenge structural racism.

STATE GENEROSITY IN HOME- AND COMMUNITY-BASED SERVICES (HCBS): VARIATIONS AND IMPACT ON DEMENTIA OUTCOMES

Abstract To meet the needs of community-living older adults and reduce overall medical spending, home- and community-based services (HCBS) provide assistance and care for persons with significant physical and cognitive limitations. Together, Medicaid long-term services and supports (LTSS) coverage and the Title III program under the Older Americans Act (OAA) of 1965 support the majority of the HCBS for older adults living in the U.S. with low-income and/or disabilities. We evaluated state variations in generosity of supporting HCBS in recent years and how these variations affect the healthcare outcomes of community-living older adults and socio-economic and racial disparities in dementia outcomes. State HCBS generosity from the perspectives of program participation and intensity of services was defined by the exploratory and the confirmatory factor analysis with data from multiple sources, including state reports from the National Association of State Budget Officers. State data was linked to a nationally representative sample of older adults who enrolled in the Health and Retirement Study in 2020. Analyses revealed that overall state supports for HCBS increased over time in recent years while state Medicaid expenditures for institutional long-term care remained largely stable. State supports through both Medicaid and the OAA programs for HCBS varied substantially and persisted in recent years. Discussion will focus on instrumental variable analyses that determine the causal impact of state variations in HCBS generosity on health outcomes (i.e., unmet need; hospitalization) for persons living with dementia persons.

Prevalence and Correlates of Unmet Medical and Social Needs in Virginia's Medicaid Managed Long Term Services and Supports Program.

Medicaid Long Term Services and Support (LTSS) programs serve individuals with complex medical and social needs. Increasingly, state Medicaid programs are contracting with managed care organizations to administer LTSS programs. Understand the prevalence of and risk factors for unmet medical and social needs among a sample of patients within a Medicaid managed LTSS program. We surveyed a cross-sectional random sample of 798 community-residing individuals over 21 in Virginia who were served by the state Medicaid managed LTSS program. Outcomes of interest include 3 distinct medical needs: medical appointments, medical transportation, and prescriptions; 4 distinct social needs: housing security, food security, utility bills, and nonmedical transportation, and composite measures of unmet social and medical needs. We found that 12.5% of our sample had any unmet medical need, while far more (62.2%) of our sample had any unmet social needs, with food insecurity being the most common. We found that members of color had almost 2 times the odds of having both unmet social and medical needs [social: adjusted odds ratio (aOR): 2.21; 95% confidence Interval (CI): (1.59, 3.09); medical aOR: 2.25 ; 95% CI: (1.34, 3.8)]. Medicaid members may not be fully realizing the potential of LTSS programs and would benefit from both Medicaid agency and managed care organizations' strategies aimed at addressing social drivers of health. To achieve health equity for LTSS members of color, Medicaid agencies may consider policies specifically targeting racial disparities.

"Let Them Know That They're Appreciated": The Importance of Work Culture on Direct Care Worker Retention.

Retaining direct care workers (DCWs) in all areas of long-term services and supports (LTSS) remains an unending challenge. The current study purposively selected 12 high-performing LTSS communities (e.g., nursing homes, assisted living, home care agencies) in Ohio with high family satisfaction and staff retention. Qualitative interviews were conducted in 2022 with 21 personnel in leadership positions and 16 DCWs (e.g., certified nursing assistants, personal care aides). Interviews were audio recorded, transcribed, and a team of two coders conducted the thematic analysis. Three themes of work culture emerged as important for retention: (1) Family-Like Organizational Approach, (2) Supportive Working Conditions, and (3) Worker Empowerment. DCWs valued empathic relationships with their clients and supervisors. Favorable working conditions consisted of choice, participative leadership, and effective communication. DCWs experienced empowerment through appreciation, financial incentives, and career advancement opportunities. Findings suggest practical changes for person-centered care practitioners that are feasible across any organizational work culture setting. [Journal of Gerontological Nursing, 49(8), 7-13.].