National Long-Term Care Survey Research Articles

Care Workers' Turnover Intentions Associated With Workplace Abuse: The Role of Work-Related Stress and Job Satisfaction.

This study examines the association between workplace abuse experienced by care workers at the hands of care recipients and their turnover intentions, as well as the mediating effects of work-related stress and job satisfaction. Compared to care recipients' experiences of abuse, care workers' experiences have been relatively underexplored. Using data from the Korean National Long-Term Care Survey in 2019, the path from workplace abuse to care workers' turnover intentions was examined. Results showed significant mediating effects of work-related stress and job satisfaction in the relationship between workplace abuse and turnover intentions. Findings have policy implications for improving long-term care workers' social awareness and working conditions.

HOW CARE WORKERS’ TURNOVER INTENTION IS ASSOCIATED WITH WORKPLACE VIOLENCE?: THE ROLE OF STRESS AND JOB SATISFACTION

Abstract This study examines the impact of workplace violence experienced by long-term care workers from the care recipients on their turnover intention and the mediating effect of work-related stress and job satisfaction in the relationship between workplace violence and turnover intention. Compared to the unfair experiences of abuses experienced by care recipients, care workers’ experiences have been relatively under-explored. Adopting the affective events theory as a theoretical framework and using the Korean National Long-Term Care Survey in 2019, the current analysis focuses on 2,427 care workers, excluding social workers, nurses, and occupational/physical therapists. The results of structural equations modeling and effect decomposition show a mediating effect of job satisfaction, indicating that the experience of workplace violence decreased the job satisfaction of care workers, resulting in increased turnover intention. On the other hand, workplace violence did not have a statistically significant indirect effect on turnover intention through work-related stress. Findings provide several implications for developing an inclusive and supportive policy and practice for care workers as well as the long-term care system in general in South Korea. Support programs and policies can be targeted toward the care workers who have experienced workplace violence and are less satisfied with their job. These can be done not only by highlighting the importance of training and education for care workers to help prevent workplace violence but also by providing a safe work environment, an appropriate compensation system, and the fair opportunities for promotion.

Preferences for private long-term care insurance products in a super-ageing society: A discrete choice experiment in Hong Kong.

There is a stark contrast between rising long-term care (LTC) demands and limited financing capacity in many ageing societies. Despite the theoretical potential of private insurance in LTC financing reforms, the reality is that the market remains remarkably underdeveloped. This study adopts a novel two-phase approach to quantitatively examine the market demand for private long-term care insurance (LTCI) in Hong Kong, one of the world's super-ageing societies. In order to examine people's preferences regarding private LTCI in Hong Kong, which has been exploring alternative LTC financing mechanisms to relieve the overburdened public system, we conducted a discrete choice experiment (DCE) in 2019 to elicit the preferences of a representative sample of 410 middle-aged adults. At first, we used data from the US National Longterm Care Survey to perform an actuarial projection for Hong Kong. In the first phase, we computed the indicative premiums based on various attributes of hypothetical private LTCI products. Undertaken in the second phase and using two econometric techniques, the DCE suggested that the most preferred hypothetical LTCI product in Hong Kong was associated with the following features: 1) a monthly benefit level of HK$20,000 or HK$25,000, 2) 3% inflation protection, and 3) 15 years of contribution. These attributes led to a monthly premium of HK$1237 (US$160)/HK$1546 (US$200) for men and HK$2150 (US$278)/HK$2687 (US$348) for women. Furthermore, we also found that the preference for LTCI products varied across people with different socioeconomic and health characteristics. These insights could inform initial market segmentation, LTCI product design, and targeted marketing in the future. This paper concludes with cautious optimism regarding the market demand for private LTCI in Hong Kong, and recommends concrete policy instruments to nurture the LTCI market, including information campaign, premium subsidies, and tax benefits.

Financial strain among unpaid family caregivers of frail elders in community

ABSTRACT In the United States, 8 out of 10 elders, 65 or older, have at least one chronic disease. Their care likely falls mostly to family members; many experience financial strain associated with providing that care. Informal caregiving saves the American healthcare system money. The economic value of family caregivers is estimated at $350 billion, exceeding the total amount spent by either Medicare ($342 billion) or Medicaid ($300 billion) The COVID-19 pandemic makes this issue even more relevant. Many of those recovering from this virus, whatever their age and previous health history, find it is a very long process. This study examined correlates of financial strain among 956 unpaid family caregivers using the framework of the stress process model. Method: The study utilized the caregiver survey data set from the 1999 National Long-Term Care Survey. Results indicate that a caregiver’s perceived overload had the largest effect on greater financial strain. Variations and dynamics in caregiver financial strain are particular to the caregiver’s family relationship. Identifying correlates of caregiver financial strain can provide an important impetus for tackling the causes and providing effective interventions.

Do Caregiving Factors Affect Hospitalization Risk Among Disabled Older Adults?

Hospitalization is common among older adults with disability, many of whom receive help from a caregiver and have dementia. Our objective was to evaluate the association between caregiver factors and risk of hospitalization and whether associations differ by dementia status. Longitudinal observational study. The 1999 and 2004 National Long-Term Care Survey and the 2011 and 2015 National Health and Aging Trends Study, linked caregiver surveys, and Medicare claims. A total of 2,589 community-living Medicare fee-for-service beneficiaries, aged 65 years or older (mean age = 79 years; 63% women; 31% with dementia), with self-care or mobility disability and their primary family or unpaid caregiver. Self-reported characteristics of older adults and their caregivers were assessed from older adult and caregiver survey interviews. Older adult hospitalization over the subsequent 12 months was identified in Medicare claims. Multivariable Cox proportional hazards models adjusted for older adult characteristics and were stratified by dementia status. In this nationally representative cohort, 38% of older adults with disabilities were hospitalized over 12 months following interview. Increased hospitalization risk was associated with having a primary caregiver who helped with healthcare tasks (adjusted hazard ratio (aHR) = 1.22; 95% confidence interval (CI) = 1.05-1.40), reported physical strain (aHR = 1.21; 95% CI = 1.04-1.42), and provided more than 40 hours of care weekly (aHR = 1.26; 95% CI = 1.04-1.54 vs ≤20 hours). Having a caregiver who had helped for 4 years or longer (vs <1 year) was associated with 38% lower risk of hospitalization (aHR = 0.62; 95% CI = 0.49-0.79). Older adults with and without dementia had similar rates of hospitalization (39.5% vs 37.3%; P = .4), and caregiving factors were similarly associated with hospitalization regardless of older adults' dementia status. Select caregiving characteristics are associated with hospitalization risk among older adults with disability. Hospitalization risk reduction strategies may benefit from understanding and addressing caregiving circumstances.

FAMILY CAREGIVER FACTORS AND HOSPITALIZATION IN DISABLED OLDER ADULTS WITH AND WITHOUT DEMENTIA

Older adults with disabilities commonly rely on family caregivers’ help, yet effects of caregiver factors on patient outcomes are poorly understood. Within this population, dementia is common. Our objective was to evaluate the association between caregiver factors and risk of hospitalization in disabled older adults with and without dementia. We examined 2,589 community-living older adults with mobility/self-care disability and their primary family caregiver in four waves of the National Long-Term Care Survey and National Health and Aging Trends Study. We used Cox proportional hazards models to examine risk of one-year, Medicare claims-derived, all-cause hospitalization as a function of caregiver factors, adjusting for older adult characteristics (sociodemographics, comorbidities, healthcare utilization) and survey year, considering dementia a characteristic of interest. Among disabled older adults, 38% were hospitalized over one year, and 31% had probable dementia. Hospitalization rates were similar for older adults with and without dementia (39.5% and 37.3% respectively); dementia was not associated with hospitalization risk (HR 1.09, 95% CI 0.95-1.26). Older adults demonstrated greater risk of hospitalization if their caregiver was male (HR 1.31, 95% CI 1.10-1.56), new to caregiving (HR 1.61, 95% CI 1.27-2.04 for < 1 year versus ≥ 4 years), or helped with healthcare tasks (HR 1.21, 95% CI 1.04-1.41). The association between most caregiving factors and hospitalization risk did not differ by dementia status. Results suggest that strategies to reduce hospitalization in older adults with disabilities could target select caregivers using similar strategies in populations with and without dementia.

Validation of the JEN frailty index in the National Long-Term Care Survey community population: identifying functionally impaired older adults from claims data

BackgroundUse of a claims-based index to identify persons with physical function impairment and at risk for long-term institutionalization would facilitate population health and comparative effectiveness research. The JEN Frailty Index [JFI] is comprised of diagnosis domains representing impairments and multimorbid clusters with high long-term institutionalization [LTI] risk. We test the index’s discrimination of activities-of-daily-living [ADL] dependency and 1-year LTI and mortality in a nationally representative sample of over 12,000 Medicare beneficiaries, and compare long-term community survival stratified by ADL and JFI.Methods2004 U.S. National Long-Term Care Survey data were linked to Medicare, Minimum Data Set, Veterans Health Administration files and vital statistics. ADL dependencies, JFI score, age and sex were measured at baseline survey. ADL and JFI groups were cross-tabulated generating likelihood ratios and classification statistics. Logistic regression compared discrimination (areas under receiver operating characteristic curves), multivariable calibration and accuracy of the JFI and, separately, ADLs, in predicting 1-year outcomes. Hall-Wellner bands facilitated contrasts of JFI- and ADL-stratified 5-year community survival.ResultsLikelihood ratios rose evenly across JFI risk categories. Areas under the curves of functional dependency at ≥3 and ≥ 2 for JFI, age and sex models were 0.807 [95% c.i.: 0.795, 0.819] and 0.812 [0.801, 0.822], respectively. The area under the LTI curve for JFI and age (0.781 [0.747, 0.815]) discriminated less well than the ADL-based model (0.829 [0.799, 0.860]). Community survival separated by JFI strata was comparable to ADL strata.ConclusionsThe JEN Frailty Index with demographic covariates is a valid claims-based measure of concurrent activities-of-daily-living impairments and future long-term institutionalization risk in older populations lacking functional information.

Long-Term Nursing Home Entry: A Prognostic Model for Older Adults with a Family or Unpaid Caregiver.

To comprehensively examine factors associated with long-term nursing home (NH) entry from 6 domains of older adult and family caregiver risk from nationally representative surveys and develop a prognostic model and a simple scoring system for use in risk stratification. Retrospective observational study. National Long-Term Care Surveys 1999 and 2004 and National Health and Aging Trends Study 2011 and linked caregiver surveys. Community-living older adults receiving help with self-care disability and their primary family or unpaid caregiver (N=2,676). Prediction of long-term NH entry (>100 days or ending in death) by 24 months follow up, ascertained from Minimum Data Set assessments and dates of death from Medicare enrollment files. Risk factors were measured from survey responses. In total, 16.1% of older adults entered a NH. Our final model and risk scoring system includes 7 independent risk factors: older adult age (1 point/5 years), living alone (5 points), dementia (3 points), 3 or more of 6 self-care activities (2 points), caregiver age (45-64: 1 point, 65-74: 2 points, ≥75: 4 points), caregiver help with money management (2 points), and caregiver report of moderate (2 points) or high (4 points) strain. Using this model, participants were assigned to risk quintiles. Long-term NH entry was 7.0% in the lowest quintile (0-6 points), 20.4% in the middle 3 quintiles (7-14 points), and 30.9% in the highest quintile (15-22 points). The model was well calibrated and demonstrated moderate discrimination (c-statistic=0.670 in the original data, c-statistic=0.647 in bootstrapped samples, c-statistic=0.652 using the point-scoring system). We developed a prognostic model and simple scoring system that may be used to stratify risk of long-term NH entry of community-living older adults. Our model may be useful for population health and policy applications.

2400 How have characteristics of end-of-life family caregiving changed from 1999 to 2015? Preliminary results from two waves of nationally representative data

OBJECTIVES/SPECIFIC AIMS: Family members are often critical in the delivery of hands-on care and decisions about care for persons approaching end-of-life (EOL). Prompted by concerns about the poor quality and high costs of care at the EOL, recent delivery reform efforts—such as the growth of hospice and palliative care—have been directed at improving EOL care for both patients and family. Trends of the characteristics of EOL family caregivers and care recipients over time have not been well described. The goal of this study is to evaluate changes in EOL family caregiving from 1999 to 2015. METHODS/STUDY POPULATION: This study uses reconciled data from two nationally representative surveys and their linked caregiver surveys: the 1999 wave of the National Long-Term Care Survey (NLTCS) and the Informal Care Survey (ICS), and the 2015 wave of the National Health and Aging Trends Study (NHATS) and the National Survey of Caregiving (NSOC). RESULTS/ANTICIPATED RESULTS: Crude analysis shows that older adults living in the community and receiving help from family caregivers in the last year of life were significantly better educated (72% with greater than 12 years of education vs. 46%), and more diverse (78% White vs. 89%) in 2015 compared with 1999. Family caregivers in the last year of life were less likely to be female in 2015 compared with 1999 (74% vs. 68%, NS) and significantly less likely to be spouses (45% vs. 38%) in 2015. In 2015, a significantly greater proportion of older adults received help with five or more activities of daily living (47% vs. 34%), but family caregivers reported significantly lower levels of caregiving-associated distress: financial strain (80% reporting none in 2015 vs. 53%), emotional (51% vs. 39%), and physical strain (70% vs. 45%). In addition, a significantly greater proportion of EOL family caregivers used respite care in 2015 compared to 1999 (15% vs. 4%). DISCUSSION/SIGNIFICANCE OF IMPACT: Changes in the experience of EOL family caregiving may be impossible to capture in studies of single interventions, but tracking nationally representative trends can be used as an indicator of broader changes that take place cumulatively over time. Although studies of this nature cannot identify causal mechanisms of change, they are important to monitor long-term impact of program implementation and to guide future research, policy, and resource allocation.

Caregiver Burden, Care Recipient Depressive Symptomology, and Social Exchange: Does Race Matter?

Informal caregivers play a vital role in supporting seriously ill patients. However, informal caregiving is burdensome and can lead to negative health outcomes for the caregiver and the care recipient. The study's aim was to evaluate relationships among caregiver burden, care recipient depressive symptomology, and race. Guided by the social exchange perspective, we examined cross-sectional dyadic data from the National Long-Term Care Survey (N = 1279). Using ordinal logistic regression, we found that higher caregiver-reported objective burden was associated with higher care recipient depressive symptoms ( P < .05), an association that was stronger for blacks. Interestingly, despite significant levels of objective burden, there was an association between lower depressive symptoms in black care recipients when there was an exchange of the social good "helpful company" with a caregiver. These findings illustrate the importance of supporting reciprocal exchange as a promising component of maintaining balanced caregiver-care recipient relationships among black older adults and their informal caregivers.

CHANGES OVER TIME IN FAMILY CAREGIVING FOR DISABLED OLDER AMERICANS, 1982–2012

This paper examines trends in informal caregiving for community-dwelling disabled older Americans between 1982 and 2012. We decompose hours of care received from spouses and children according to changes in: (a) the number of potential spousal and child caregivers (“family structure”), (b) the likelihood that existing spouses and children are caregivers (“the propensity to give care”), and (c) the amount of care provided by individual spousal and child caregivers (“caregiving intensity”). We use data from two nationally representative surveys, the National Long-Term Care Survey (1982 and waves every five years from 1984 through 2004) and the Health and Retirement Study (waves every two years from 2000 through 2012). Disabled older people reported having fewer informal caregivers in 2012 than they did 30 years earlier. Hours of care received from spouses, children, and other family members declined during the 1990’s but have remained fairly constant since then. With regard to the decompositions, existing spouses’ and children’s decreasing likelihood of being caregivers led to fewer spousal and child caregivers per disabled older person in 2012 than in 1982, but the amount of care provided by individual spousal and child caregivers has been similar across the thirty years. Because the intensity of care provided by individual family caregivers has remained fairly constant since the early 1980s, the needs of family caregivers who experience high stress and a high time burden continue to deserve our attention.

Trends in Informal Care for Disabled Older Americans, 1982-2012.

We examine trends in informal care from the perspective of both community-dwelling disabled older Americans and their caregivers from 1982 to 2012. We decompose hours of care received from spouses and children according to changes in: (a) the number of potential spousal and child caregivers ("family structure"), (b) the likelihood that existing spouses and children are caregivers ("caregiving propensity"), and (c) the amount of care provided by individual caregivers ("time burden"). We examine two sets of time trends based on distinct samples of community-dwelling disabled older Americans from the 1982-2004 waves of the National Long-Term Care Survey (NLTCS) and the 2000-2012 waves of the Health and Retirement Study (HRS). Existing spouses' and children's decreasing likelihood of being caregivers led to fewer spousal and child caregivers per disabled older person in the 2004 NLTCS than the 1982 NLTCS. However, the NLTCS and HRS time trends suggest that the amount of care provided by individual caregivers was similar from 1989 to 2012. Because individual caregivers' time burden has remained fairly constant since at least 1989, advocacy on behalf of policies that promote more and better support for caregivers is appropriate.

Race Differences in ADL Disability Decline 1984-2004: Evidence From the National Long-Term Care Survey.

Disability declined in lower levels of impairment during the late 20th century. However, it is unclear whether ADL disability also declined, or whether it did so across race. In this study, we examine cohorts entering later life between 1984 and 1999, by race, to understand changing ADL disability. We used latent class methods to model trajectories of ADL disability and subsequent mortality in the National Long-Term Care Survey among cohorts entering older adulthood (ages 65-69) between 1984 and 1999. We examined patterns by race, focusing on chronic condition profiles. White cohorts experienced consistent declines in ADL disability but Blacks saw little improvement with some evidence for increased disability. Stroke, diabetes, and heart attack were predominant in predicting disability among Blacks. Declining disability trends were only observed consistently among Whites, suggesting previous and future disability trends and their underlying causes should be examined by race.

Perceived overload as a predictor of physical strain among spousal and adult child caregivers of frail elders in the community

ABSTRACTFamily caregivers of frail elders can experience physical strain associated with caregiving. Identifying correlates of caregiver strain can provide an important impetus for tackling the causes and providing effective interventions. Utilizing data from the 1999 National Long-Term Care Survey, the current study examined correlates of caregiver physical strain among 956 family caregivers, using the stress process model. As multiple regression analyses indicated, the caregiver’s perceived overload predicted greater strain for both spousal and adult child caregivers. For both groups, common correlates of physical strain were caregiving demands, the caregiver’s perceived overload, and limitations placed on the caregiver’s life. The results demonstrate that the family relationship of the caregiver (spouse or adult child) leads to variations and dynamics in caregiver strains, due to qualitatively different relationships.

The modeling of medical expenditure data from a longitudinal survey using the generalized method of moments (GMM) approach.

Medical expenditure data analysis has recently become an important problem in biostatistics. These data typically have a number of features making their analysis rather difficult. Commonly, they are heavily right-skewed, contain a large percentage of zeros, and often exhibit large numbers of missing observations because of death and/or the lack of follow-up. They are also commonly obtained from records that are linked to large longitudinal data surveys. In this manuscript, we suggest a novel approach to modeling these data through the use of generalized method of moments estimation procedure combined with appropriate weights that account for both dropout due to death and the probability of being sampled from among the National Long Term Care Survey (NLTCS) subjects. This approach seems particularly appropriate because of the large number of subjects relative to the length of observation period (in months). We also use a simulation study to compare our proposed approach with and without the use of weights. The proposed model is applied to medical expenditure data obtained from the 2004-2005 NLTCS-linked Medicare database. The results suggest that the amount of medical expenditures incurred is strongly associated with higher number of activities of daily living (ADL) disabilities and self-reports of unmet need for help with ADL disabilities. Copyright © 2016 John Wiley & Sons, Ltd.

Unmet Need for Help With Activities of Daily Living Disabilities and Emergency Department Admissions Among Older Medicare Recipients.

This study determined whether self-reports of unmet need for help with activities of daily living (ADL) disabilities are prognostic of emergency department (ED) utilization. This prospective cohort study of 2,194 community-living, ADL-disabled subjects combined 2004 National Long-Term Care Survey responses with linked Medicare data through 2005. A negative binomial count model was computed to assess the association between unmet ADL need and number of subsequent ED admissions while statistically adjusting for predisposing, enabling, and need characteristics associated with ED admissions among older adults. The adjusted annual incidence rate (IR) for ED admissions was 19% higher for unmet versus met need (IR = 1.19; 95% confidence interval [CI] = 1.00-1.40; p = .047). The IR for ED admissions for falls and injuries was higher for those with unmet ADL versus met ADL need (IR = 1.43; 95% CI = 1.10-1.86), and trended toward significance for ED admissions for skin breakdown (IR = 2.02; 95% CI = 0.97-2.88), but was not significant for ED admissions for dehydration (IR = 1.13; 95% CI= 0.79-1.63). Unmet ADL need is prognostic of ED admissions, especially for falls and injuries. Future research is needed to determine whether resolution of unmet ADL need reduces ED utilization.

Physical Activity and Self-Rated Health Status Among Older Adult Cancer Survivors: Does Intensity of Activity Play a Role?

To examine the association between routine physical activity and self-rated health status in older adults with cancer.. Cross-sectional. Community-dwelling older adult survivors who completed a screening tool and subsequent detailed interview from the 2004 wave of the National Long-Term Care Survey, a nationally representative study of Medicare beneficiaries aged 65 years or older. 251 older adult cancer survivors who regularly engaged in routine physical activity. Participants were asked about chronic health conditions, depression, activities of daily living, participation in physical activities, self-rated health status, and sociodemographic characteristics. A weighted ordered probit model was used to estimate variables that predict self-reported health status. Self-rated health status and participation in physical activity. Age and higher education level were found to be significant correlates of health status (p < 0.05) in the first model. Although education was not significant in subsequent models, age, functional disability, and depression all were identified as significant correlates of health status (p < 0.01). In the final model, in which moderate and vigorous activity participation were entered, older adult survivors who engaged in vigorous physical activity showed higher levels of health status than those who engaged in light physical activity (p < 0.05), but number of chronic health conditions was not significantly associated with health status. The association between vigorous activity and health status points to the primacy of physical activity within a post-cancer treatment health regimen. . Health programs and policies need to address physical activity to improve the overall well-being of older adult cancer survivors.

Delivery of institutional long-term care under two social insurances: Lessons from the Korean experience

Little is known about health and social care provision for people with long-term care (LTC) needs under multiple insurances. The aim of this study is to compare the profile, case-mix, and service provision to older people at long-term care hospitals (LTCHs) covered by the national health insurance (NHI) with those of older people at long-term care facilities (LTCFs) covered by the public long-term care insurance (LTCI) in Korea. A national LTC survey using common functional measures and a case-mix classification system was conducted with a nationally representative sample of older people at LTCFs and LTCHs in 2013. The majority of older people in both settings were female and frail, with complex chronic diseases. About one fourth were a low-income population with Medical-Aid. The key functional status was similar between the two groups. As for case-mix, more than half of the LTCH population were categorized as having lower medical care needs, while more than one fourth of the LTCF residents had moderate or higher medical care needs. Those with high medical care needs at LTCFs were significantly more likely to be admitted to acute-care hospitals than their counterparts at LTCHs. The current delivery of institutional LTC under the two insurances in Korea is not coordinated well. It is necessary to redefine the roles of LTCHs and strengthen health care in LTCFs. A systems approach is critical to establish person-centered, integrated LTC delivery across different financial sources.

Who pays for home care? A study of nationally representative data on disabled older Americans.

BackgroundWe examine who pays for services that support disabled older Americans at home. We consider both personal sources (e.g., out-of-pocket payment, family members) and publicly funded programs (e.g., Medicaid) as sources of payment for services. We examine how the funding mix for home care services is related to older people’s economic resources, needs for care, and other socio-demographic characteristics.MethodsOur sample consists of 11,725 person-years from the 1989, 1994, 1999, and 2004 waves of the National Long-Term Care Survey. Two-part regression analyses were performed to model hours of care received from each payer. “Random effects” and “fixed effects” estimation yielded similar results.ResultsAbout six in ten caregivers (63 %) providing home care services are paid by personal sources alone. By contrast, 28 % receive payment from publicly funded programs alone, and 9 % from a combination of personal and public program sources. Older people with family incomes over 75,000 dollars per year receive 8.5 more hours of home care overall than those in the lowest income category (less than 15,000 dollars). While the funding mix for home care services is strongly related to older people’s economic resources, in all income groups at least 65 % of services are provided by caregivers paid in whole or in part from personal sources. In fact, almost all (97 %) home care received by those with family incomes over 75,000 dollars per year are financed by personal sources alone.ConclusionsWe outline the implications that heavy reliance on personally financed services and economic disparities in overall services use has for disabled older Americans and their families.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-0978-x) contains supplementary material, which is available to authorized users.

Caregiver Stress: Does States’ Expenditure on Home- and Community-Based Services Matter?

This study examined how state expenditure on home- and community-based services (HCBS) and individual factors are associated with caregiver stress. A total of 1,849 cases from the 2004 National Long-Term Care Survey were included. Gender, education, perceived physical strain, and economic hardship, as well as the number of limitations in instrumental activities of daily living (IADL) for the care recipient, were associated with caregiver stress. The cross-level interaction between service utilization and state expenditure on HCBS was significant, suggesting that living in states with a higher expenditure on HCBS is associated with reduced stress regardless of service utilization.