Long-term Institutionalization Research Articles

Outcomes of Medicaid Rebalancing May Differ Across Enrollee Populations.

Access to home- and community-based services (HCBS) may prevent or delay nursing home transitions among older adults. Medicaid's Balancing Incentive Program (BIP) (2011-2015) provided assistance for U.S. states to increase access to HCBS through infrastructure changes and spending benchmarks. We combined longitudinal data from the 2008-2019 Medicare Current Beneficiary Survey and Minimum Data Set and used survival modeling to examine the association between BIP exposure (living in a BIP-participant state vs. not) and time to long-term institutionalization (LTI, defined as a nursing home episode of 90+ days) among dual enrollees ages 65 and older. In the main effects model, BIP exposure was not associated with hazard of LTI. Interaction models showed that BIP exposure was associated with a lower hazard of LTI among Hispanic/Latinx enrollees, while the opposite was true among non-Hispanic White enrollees. Our findings suggest the outcomes of Medicaid rebalancing efforts may differ across enrollee subgroups.

Healthcare policy to support people living with HIV infection and AIDS patients

Background: Individuals living with human immunodeficiency virus (HIV) encounter challenges throughout the care continuum, right from the time of diagnosis to the culmination of the treatment process.Current Concepts: The Republic of Korea, like many other countries, has been addressing the needs of people living with HIV (PLWH) by providing financial support for medical expenditures. Currently, HIV counseling specialist nurses offer psychological support at 28 institutions, assisting patients in maintaining viral suppression state and adhering to antiretroviral therapy. Care and welfare services are also provided by non-governmental organizations funded by the Korean Disease Control and Prevention Agency (KDCA). The accessibility of medical institutions for PLWH has seen gradual improvement, with KDCA issuing guidelines for healthcare facilities catering to this population. In addition, the legal and medical insurance coverage issues related to long-term care institutionalization have been addressed. However, PLWH continues to face challenges in treatment and hospitalization, especially with a recent increase in immigrant PLWH, highlighting a lack of support for undocumented immigrants seeking treatment.Discussion and Conclusion: Healthcare policies are shifting from merely managing, isolating, and treating PLWH to prioritizing their human rights. Going forward, it is imperative to empower PLWH and support their self-care efforts.

A percepção dos idosos sobre a institucionalização de longa permanência

O envelhecimento da população brasileira é uma realidade que vem sendo percebida há algumas décadas e que tende a se tornar ainda maior com o passar dos anos. Quando o envelhecimento resulta em senilidade, muitas vezes os familiares precisam abrigar os idosos em Instituições de Longa Permanência (ILPIs), nas quais pode ocorrer a perda da singularidade dos indivíduos. Nesse contexto, é de grande importância que os enfermeiros conheçam a realidade do idoso, a partir do seu próprio ponto de vista. Objetivos: Compreender os sentimentos e percepções apresentados por idosos residentes em duas ILPIs do oeste do estado de São Paulo. Método: Pesquisa descritiva, exploratória, com abordagem qualitativa. Os sujeitos da pesquisa foram sete idosos residentes em duas ILPIs do oeste do estado de São Paulo. Os dados foram coletados por meio de entrevistas gravadas e transcritas, que posteriormente foram analisadas segundo a análise de conteúdo temática, levantando duas categorias temáticas: 1) Sentimentos relacionados à história pessoal e 2) Impressões sobre as relações na ILPI. Resultados: Os sentimentos identificados nos discursos foram especialmente perda, solidão, inutilidade e culpa. Em relação às ILPIs, emergiram sentimentos de satisfação e insatisfação. Considerações Finais: As percepções advindas da análise dos resultados podem promover reflexões nos profissionais e gestores das ILPIs. É importante também que as equipes de trabalho possam ser compostas por profissionais diversificados e capazes de atender as necessidades enfrentadas pelos idosos institucionalizados.

VETERAN DIRECTED CARE: A MIXED METHODS STUDY TO INFORM SELF DIRECTED CARE PROGRAM EXPANSION FOR VETERANS AFFAIRS (VA)

Abstract The Department of Veterans Affairs (VA) is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program, a self-directed program in which Veterans choose services and employ their providers to avoid or delay long-term institutionalization. The VA plans to expand VDC to all VA facilities by FY2026, but factors affecting VDC expansion are poorly understood. We focused on facilitators and barriers in the seven Veterans Integrated Service Network (VISN) 8 VDC programs between May 2022 and January 2023 to inform program expansion. We used a mixed-methods approach, with surveys followed by semi-structured interviews with VA VDC staff, their partners at Aging and Disability Network Agencies (ADNAs) and VISN 8 leadership, such as lead program coordinators, using the Consolidated Framework for Implementation Research to guide the project rapid analysis techniques. We found substantial variability in the structure, size, and operations of the VDC programs reflecting challenges noted by respondents. VA staff were consistently enthusiastic about VDC’s quality benefits for Veterans, however, they recommended additional staff, a dedicated VDC coordinator, and a national guidebook or standard operating procedures to streamline processes. Respondents also noted the need for more program education targeting referring providers. Unique local challenges, like the lack of available caregivers or no local ADNA, and limited local leadership support were other factors noted that could limit expansion. Importantly, Veterans were often overwhelmed by the employer responsibilities they needed to fulfill. Addressing these concerns remains a challenge to VISN 8 and national leadership.

Comparison of Claims-Based Frailty Indices in U.S. Veterans 65 and Older for Prediction of Long-Term Institutionalization and Mortality.

Frailty is increasingly recognized as a useful measure of vulnerability in older adults. Multiple claims-based frailty indices (CFIs) can readily identify individuals with frailty, but whether 1 CFI improves prediction over another is unknown. We sought to assess the ability of 5 distinct CFIs to predict long-term institutionalization (LTI) and mortality in older Veterans. Retrospective study conducted in U.S. Veterans ≥65 years without prior LTI or hospice use in 2014. Five CFIs were compared: Kim, Orkaby (Veteran Affairs Frailty Index [VAFI]), Segal, Figueroa, and the JEN-FI, grounded in different theories of frailty: Rockwood cumulative deficit (Kim and VAFI), Fried physical phenotype (Segal), or expert opinion (Figueroa and JFI). The prevalence of frailty according to each CFI was compared. CFI performance for the coprimary outcomes of any LTI or mortality from 2015 to 2017 was examined. Because Segal and Kim include age, sex, or prior utilization, these variables were added to regression models to compare all 5 CFIs. Logistic regression was used to calculate model discrimination and calibration for both outcomes. A total of 3 million Veterans were included (mean age 75, 98% male participants, 80% White, and 9% Black). Frailty was identified for between 6.8% and 25.7% of the cohort with 2.6% identified as frail by all 5 CFIs. There was no meaningful difference between CFIs in the area under the receiver operating characteristic curve for LTI (0.78-0.80) or mortality (0.77-0.79). Based on different frailty constructs, and identifying different subsets of the population, all 5 CFIs similarly predicted LTI or death, suggesting each could be used for prediction or analytics.

노화와 근감소증

With aging, skeletal muscle mass and its function decrease, and the changes lead to increased risk of falls, fractures, long-term care institutionalization, mortality, and even cardiovascular and metabolic diseases. Sarcopenia has been defined as low muscle mass together with low muscle strength and/or low physical performance. In 2019, Asian Working Group for Sarcopenia(AWGS) published a consensus paper about diagnosis and management of sarcopenia. The AWGS 2019 proposed algorithm starting with measuring SARC-F questionnaire or calf circumference (cut-off, <34 cm in men, <33 cm in women) and then measuring handgrip strength (cut-off, <28 kg in men, <18 kg women) or 5-time chair stand test (≥12 sec), and then ‘possible sarcopenia’ can be defined. Low appendicular skeletal muscle mass and either low muscle strength (handgrip strength) or low physical performance (gait speed or 5-time chair stand test) is used to diagnose sarcopenia. For management of sarcopenia, high protein nutrition and resistance exercise are highly recommended, and vitamin D may increase muscle strength, particularly in vitamin D deficiency.

Wade Taylor: A Family Haunting

This article explores neurodiversity, eugenics, and Appalachian identity in the early twentieth-century American South through the lens of the author's family history. It discusses the loss of a relative to long-term institutionalization. The article proposes that the central premise of the ideology and pseudoscience of eugenics—that deviance, disability, and most social ills are hereditary—posed a sufficient threat to families with disabled members to enforce their complicity with ableist practices and social structures in many cases, especially when paired with virtually nonexistent home- and community-based services. It also suggests that insufficient home- and community-based services continue to drive disabled people into institutions against their will to this day.

MEASURING UNMET NEEDS OF HIGH-NEED, HIGH-RISK AMERICAN VETERANS AND THEIR CAREGIVERS USING A PROSPECTIVE SURVEY

Abstract Success in delaying long term institutionalization (LTI) depends on creating means to adequately support each Veteran’s needs. To better understand the unmet needs of Veterans, we identified a random sample of 20,000 Veterans from five VA sites. Veterans were stratified into low-, moderate- or high-risk tiers using a measure of predicted 2-year probability of LTI. Veterans and their caregivers were asked to complete separate surveys to assess demographic, physical, psychological, and social domains, unmet needs, and experience with HCBS and caregiver support programs. Responses were received between July-Dec 2021 from 8056 Veterans (80.3+/-9.8y; 94.0% men; 82.6% White; 8.9% Hispanic) and 3579 caregivers (71.1+/-13.1y; 75.1% women; 80.5% White; 15.1% Hispanic; 57.1% spousal) responded by mail (96%) or online (4%). Both Veterans and caregivers endorse complex Veteran unmet needs spanning medical, psychological, and social domains. Survey results will be used to inform HCBS policy to support aging Veterans and their caregivers.

Delirium detection using GAMMA wave and machine learning: A pilot study.

Delirium occurs in as many as 80% of critically ill older adults and is associated with increased long-term cognitive impairment, institutionalization, and mortality. Less than half of delirium cases are identified using currently available subjective assessment tools. Electroencephalogram (EEG) has been identified as a reliable objective measure but has not been feasible. This study was a prospective pilot proof-of-concept study, to examine the use of machine learning methods evaluating the use of gamma band to predict delirium from EEG data derived from a limited lead rapid response handheld device. Data from 13 critically ill participants aged 50 or older requiring mechanical ventilation for more than 12 h were enrolled. Across the three models, accuracy of predicting delirium was 70 or greater. Stepwise discriminant analysis provided the best overall method. While additional research is needed to determine the best cut points and efficacy, use of a handheld limited lead rapid response EEG device capable of monitoring all five cerebral lobes of the brain for predicting delirium hold promise.

Role of Electroconvulsive Therapy in Treatment-Resistant Schizophrenia in Forensic Psychiatry.

Long-term institutionalization of the forensic psychiatry patient population places a psychological burden on patients and family members as well as a financial burden on the health care system at large. Although electroconvulsive therapy is a well-established tool for patients with treatment-resistant schizophrenia, it is infrequently used in the forensic setting. This review serves to demonstrate an example of electroconvulsive therapy in combination with clozapine as a means of reducing length of hospitalization in a forensic psychiatric patient. Furthermore, this review will discuss factors limiting the prescribing of electroconvulsive therapy to this patient population including ethical considerations and availability.

Risk Factors for Institutionalization Among the Elderly: A Systematic Literature Review

Objective(s) To provide a systematic review of the risk factors for long-term institutionalization in older adults living in developed countries. Data Sources A systematic search of the following scholarly databases was conducted: PubMed, CINAHL, Web of Science, and Cochrane Library. Study Selection English language articles, with a primary or secondary outcome of institutionalization, published from January 2010 to September 2020 were identified. Studies assessing multivariate predictors for institutionalization among the elderly were included. Data Extraction Titles, abstracts, and full-text articles were independently reviewed by all authors to determine study eligibility. Data Synthesis A total of 1,358 studies were identified. Among eligible studies, 100 studies met the inclusion criteria. Consistent multivariate predictors for institutionalization were increased age, low education status, one or more comorbidities, functional and/or cognitive impairment, neurological/circulatory disorders (e.g., stroke), urological disorders (e.g., urinary incontinence), environmental factors (e.g., caregiver burden), and medical histories (e.g., emergency department visits). The female gender emerged as a predictor for institutionalization across disease groups such as stroke, chronic conditions, Alzheimer's Disease, and mood disorders, except for dementia. Race was a significant predictor of institutionalization only for dementia patients (White vs non-white). Conclusions Findings suggest that multivariate predictors for increased risk of institutionalization among older adults primarily stem from underlying cognitive and/or functional impairment, and associated environmental factors, such as caregiver burden or loneliness. Inconsistencies in race predicting institutionalization can be attributed to differences in study samples and methodological differences in racial group comparisons, and variation observed in female risk for institutionalization is possibly influenced by gender socialization and physiological differences. Author(s) Disclosures All authors report no financial relationships or financial conflicts of interest. To provide a systematic review of the risk factors for long-term institutionalization in older adults living in developed countries. A systematic search of the following scholarly databases was conducted: PubMed, CINAHL, Web of Science, and Cochrane Library. English language articles, with a primary or secondary outcome of institutionalization, published from January 2010 to September 2020 were identified. Studies assessing multivariate predictors for institutionalization among the elderly were included. Titles, abstracts, and full-text articles were independently reviewed by all authors to determine study eligibility. A total of 1,358 studies were identified. Among eligible studies, 100 studies met the inclusion criteria. Consistent multivariate predictors for institutionalization were increased age, low education status, one or more comorbidities, functional and/or cognitive impairment, neurological/circulatory disorders (e.g., stroke), urological disorders (e.g., urinary incontinence), environmental factors (e.g., caregiver burden), and medical histories (e.g., emergency department visits). The female gender emerged as a predictor for institutionalization across disease groups such as stroke, chronic conditions, Alzheimer's Disease, and mood disorders, except for dementia. Race was a significant predictor of institutionalization only for dementia patients (White vs non-white). Findings suggest that multivariate predictors for increased risk of institutionalization among older adults primarily stem from underlying cognitive and/or functional impairment, and associated environmental factors, such as caregiver burden or loneliness. Inconsistencies in race predicting institutionalization can be attributed to differences in study samples and methodological differences in racial group comparisons, and variation observed in female risk for institutionalization is possibly influenced by gender socialization and physiological differences.

Admission to the Long-Term Care Facilities and Institutionalization Rate in Community-Dwelling Frail Adults: An Observational Longitudinal Cohort Study.

The worldwide aging and the increase of chronic disease impacted the Health System by generating an increased risk of admission to Long-Term Care (LTC) facilities for older adults. The study aimed to evaluate the admission rate to LTC facilities for community-dwelling older adults and investigate factors associated with these admissions. A secondary data analysis stemming from an observational longitudinal cohort study (from 2014 to 2017) was performed. The sample was made up by 1246 older adults (664 females and 582 males, mean age 76.3, SD ± 7.1). The LTC facilities access rate was 12.5 per 1000 observations/ year. Multivariable Linear Regression identified frailty, cardiovascular disease, and incapacity to take medicine and manage money as predictors of the LTC facilities’ access rate. The Multiple Correspondence Analysis identified three clusters: those living at home with comorbidities; those living in LTC facilities who are pre-frail or frail; those very frail but not linked to residential LTC. The results indicate that access to LTC facilities is not determined by severe disability, severe comorbidity, and higher frailty levels. Instead, it is related to moderate disability associated with a lack of social support. Therefore, the care policies need to enhance social interventions to integrate medical, nursing, and rehabilitative care.

The Digital Divide Amongst High-Need High-Risk Veterans

High-need high-risk (HNHR) veterans are medically complex and at the highest risk of hospitalization and long-term institutionalization. Technology can mitigate challenges these veterans have in accessing healthcare. Willingness to use technology as well as access and ability to use technology were assessed in this study. At the time of the survey, 2543 Miami VAHS veterans were listed as HNHR. 634 veterans ultimately completed the questionnaire, and 602 answered the “willingness to use video-visits” question. Of the 602 respondents, 327 (54.3%) reported they were willing for video-visits with the VA, while 275 (45.6%) were not. Those who were willing were significantly younger (P<0.001), with higher educational qualifications (P=0.002), and more health literate than those not willing (P<0.001). They were more also capable of using the Internet, more likely to use email and be enrolled in the VA’s patient portal, My HealtheVet (P<0.001). However, of the veterans who were willing, 248 (75.8%) had a device with video-capable technology. Those with video-capable technology were younger (P=0.004), more health literate (P=0.01), and less likely to be Black or African American (P=0.007). They were more capable of using the Internet, more likely to use email, and be enrolled in My HealtheVet than those without (P<0.001). Half of the respondents were willing for video-visits but a quarter of those willing lacked requisite technology, thereby making only about 41.2% of the respondents willing and video-capable. To minimize the digital divide, especially during the ongoing COVID-19 pandemic, targeted measures need to address these disparities in this vulnerable population.

Derivation and Validation of a Predictive Algorithm for Long-Term Care Admission or Death

ObjectivesOlder veterans prefer to remain in their homes and communities as long as possible. Although targeted delivery of home- and community-based services for veterans might delay long-term care placement, often, access to these services is inconsistently organized or delayed. To aid in early recognition of veterans at high risk for long-term care placement or death, we developed and validated a predictive algorithm, “Choose Home.” DesignA retrospective observational cohort analysis was used. Setting and ParticipantsTwo cohorts of Veterans Health Administration (VHA; a large integrated health care system) users were assembled: Derivation (4.6 million) and Confirmation (4.7 million). The Derivation Cohort included Veterans Administration users from fiscal year 2013; the Confirmation Cohort included Veterans Administration users from fiscal year 2014. MethodsA total of 148 predictor variables, including demographics, comorbidities, and utilizations were selected using logistic regression to predict placement in a long-term care facility for >90 days or death within 2 years. ResultsVeterans were predominantly male [92.8% (Derivation), 92.5% (Confirmation)] and older [61.7±15.5 (Derivation), 61.5±15.6 years (Confirmation)], with a high prevalence of comorbid conditions. Between the Derivation and Confirmation Cohorts, the areas under the receiver operating characteristic curves were found to be 0.80 [95% confidence interval (CI) 0.799, 0.802] and 0.80 (95% CI 0.800, 0.802), respectively, indicating good discrimination for determining at-risk veterans. Conclusions and ImplicationsWe created a predictive algorithm that identifies veterans at highest risk for long-term institutionalization or death. This algorithm provides clinicians with information that can proactively inform clinical decision making and care coordination. This study provides the groundwork for future investigations on how home- and community-based services can target older adults at highest risk to extend time in their communities.

VA home-based primary care interdisciplinary team structure varies with Veterans' needs, aligns with PACE regulation.

Interdisciplinary team (IDT) care is central to home-based primary care (HBPC) of frail elders. Traditionally, all HBPC disciplines managed a patient (Full IDT), a costly approach to maintain. The recent PACE (Program of All-inclusive Care for the Elderly) regulation provides for a flexible approach of annual assessments from a core team with involvement of additional disciplines dependent upon patient needs (Core+). Current Department of Veterans Affairs (VA) HBPC guidance specifies Full IDTs care for medically complex and functionally impaired Veterans similar to PACE participants. We evaluated whether VA HBPC has adopted the flexible structure of the PACE regulation, aligned to Veteran needs. Cross-sectional analysis. All 139 VA HBPC programs administered across 379 sites. About 55,173 Veterans enrolled in HBPC during fiscal year 2018. Patients' HBPC physician, nurse, psychologist/psychiatrist, social worker, therapist, dietitian, and pharmacist visits were grouped into interdisciplinary team types. Patient frailty was classified using VA HNHR v2 (High-Need High-Risk version 2, a measure of high, medium, and low risk of long-term institutionalization). Medical complexity was measured by clusters of impairment in the JEN frailty index (JFI). JFI clusters were validated by VA's Nosos measure to project cost and Care Assessment Need (CAN) measure of hospitalization and mortality risk. HBPC provided Full IDT care to 21%, Core+ care to 54%, and Home Health+ (HHA+) care (skilled home health services plus additional disciplines, without primary care) to 16% of Veterans. Team type was associated with medical complexity (X2 2863.5 [66 df], p < 0.0001). High-risk Veterans (72% of sample) were more likely to receive Full IDT care (X2 62.9, 1 df), p < 0.0001), while low-risk Veterans (28%) were more likely to receive HHA+ care (X2 314.8, 1 df, p < 0.0001). There is a strong association between HBPC team patterns and patient frailty, indicating tailoring of care to match Veteran needs.

Impacts of therapeutic horticulture on happiness and loneliness in institutionalized clients with mental health conditions

Introduction Therapeutic horticulture (TH) can be considered a non-pharmacological approach to support psychiatric treatments for the improvement of physical and mental health, but information is lacking on whether it has advantages as compared to more conventional occupational therapies (OTs). Method The study focused on institutionalized 25 clients attending TH among other OTs and 15 clients attending OT other than TH. The measures used were the ‘Subjective Happiness Scale’ (SHS) and the ‘Social and Emotional Loneliness Scale for Adults’ (SELSA-S), along with sociodemographic and clinical data. The study design was descriptive, observational and cross-sectional. Results Scores obtained from the SHS and SELSA-S were generally similar for both groups, although 40% of clients in the TH group perceived relaxation. These are in agreement with previous studies performed with chronic schizophrenia clients reporting that TH might effectively decrease depression/anxiety symptoms, but the feeling of hopelessness and quality of life did not change, probably due to long-term institutionalization and required medication that may limit other effects. Within the TH group, clients preferred specific horticultural tasks and more days/week attending activities decreased loneliness and increased happiness. Conclusion TH interventions as an integrative treatment option merits further study on both process and outcome evaluation, to maximize its effectiveness.

A cross-case analysis of developing program sustainability and institutionalization in early stages of a multisite biomedical student diversity initiative

BackgroundGrant funding often drives innovative programming in efforts to enhance diversity in biomedical fields, yet strategies for sustainability of grant-funded biomedical intervention are not well understood. Additionally, as funding agencies shift toward supporting institutional change to biomedical training, less is known about the extent to which sustainability strategies can support long-term institutionalization of the original goals of the grant-funded initiative. The purpose of this study is twofold: to identify strategies used by grant-funded programs for promoting sustainability, and to examine the interrelations between the concepts of sustainability and institutionalization during early stages of grant-funded biomedical career training efforts.MethodsWe employed a multiple case study design and cross-case analysis using interviews of program administrators and participants from 10 undergraduate institutions that received Building Infrastructure Leading to Diversity (BUILD) awards funded by the National Institutes of Health (NIH).ResultsBUILD sites engaged in the following strategies to develop program sustainability: 1) scaling and adapting to expand programmatic impact, 2) identifying additional funding and cost-cutting measures, 3) developing and maintaining infrastructure and structural operations, 4) leveraging relationships and with intra-and inter-institutional partners, and 5) and addressing hiring, policies, and reward systems at the institution. Senior administrative support supported program sustainability and early institutionalization, although we also identified situations where participants felt that they were on track for sustainable changes without administrative support or institutional change. Of the strategies identified, those that involve organizational and infrastructural changes contribute to early stages of institutionalization.ConclusionsThis study contributes to literature on organizational change by providing evidence of distinctions and interrelations between program sustainability efforts and institutionalization of change efforts in that some sustainability strategies can overlap with strategies to move toward institutionalization. The findings indicate the importance of program administrators developing early sustainability plans that also lead to institutionalization, as well as an opportunity for funding agencies to develop technical assistance on sustainability, organizational change, and institutionalization as a resource to support program administrators’ efforts toward making lasting, structural change on their campuses.

Short Physical Performance Battery as a Crosswalk Between Frailty Phenotype and Deficit Accumulation Frailty Index.

Growing evidence supports the clinical importance of evaluating frailty in older adults, with its strong outcome relevance. We aimed to assess whether the Short Physical Performance Battery (SPPB) correlates with frailty status according to phenotype and deficit accumulation models and can be used as a link between these models. We analyzed records of 1064 individuals from the Aging Study of Pyeongchang Rural Area, a population-based, prospective cohort from South Korea. Frailty was determined using the Cardiovascular Health Study (CHS) phenotype (phenotype model), 26- and 34-item frailty indices (deficit accumulation model). Associations of SPPB score and frailty with a composite outcome of mortality or long-term institutionalization were assessed. Crosswalks for SPPB, the CHS frailty phenotype, and the frailty index were created. The mean age of the study population was 76.0 years, and 583 (54.8%) were women. According to the CHS phenotype, 26- and 34-item frailty indices, 242 (22.7%), 161 (15.1%), and 280 (26.3%) participants, respectively, had frailty. Sensitivities/specificities for classifying CHS phenotype, 26- and 34-item frailty indices were 0.93/0.55, 0.71/0.84, and 0.80/0.83 by SPPB cut points of ≤9, ≤6, and ≤7, respectively. C-index of SPPB score (0.78) showed a predictive ability for the composite outcome that was comparable to that of CHS frailty phenotype (0.79), 26- (0.78), and 34-item frailty indices (0.79). We could create a crosswalk linking frailty phenotype and frailty index from correlations between SPPB and frailty models. This result may facilitate clinical adoption of the frailty concept in a broader spectrum of older adults.

A New Stage of the Caregiving Career: Informal Caregiving After Long-term Institutionalization.

The "unexpected career" of caregiving has previously been conceptualized in stages: community care through institutional placement/residence, ending with death of the care recipient. Transition programs such as Money Follows the Person (MFP) created a new stage of the caregiving career, caring for someone post-long-term institutionalization, about which little is known. Using Pearlin's Caregiver Stress Process Model, this study explores effects on caregivers from the return of their loved ones to the community after a long-term institutional stay. Cross-sectional surveys of 656 caregivers of persons transitioned through Connecticut's MFP program 2014-2018, completed 6 months posttransition. Regardless of the age/disability of the care recipient, and despite experiencing high caregiving intensity, caregivers experienced less burden, anxiety, and depression, and higher benefits of caregiving than demonstrated in literature for the general caregiving population. Most felt less stressed than before and during the participant's institutional stay. Factors associated with worse outcomes included worry about safety, strained finances, missing work, and desiring additional services. Black and Hispanic caregivers experienced lower burden and anxiety and higher benefits of caregiving than White caregivers. By providing community supports to participants, transition programs can have broad ancillary benefits for caregivers and improve outcomes in the Pearlin model, lessening potentially deleterious effects of an unexpected return to intensive caregiving duties after institutional placement. Positive results for Black and Hispanic caregivers may reflect cultural expectations in caring for family that buffer the adverse effects of caregiving.

Special Report: America’s First Asylum for African Americans Marks 150th Anniversary

<i>Special Report:</i> America’s First Asylum for African Americans Marks 150th Anniversary