Nursing Home Use Research Articles

Should I stay or should I go again: Multiple switching between fee-for-service Medicare and Medicare advantage among older beneficiaries.

To evaluate whether having previously disenrolled from Medicare Advantage (MA) is associated with lower hazards of future MA enrollment. Secondary data from Medicare. We examined beneficiaries with baseline FFS enrollment from 2017-2019 using a 20% sample of Medicare claims. Cox proportional hazard models were used to examine the association of prior MA enrollment (in the three years prior to baseline FFS enrollment) with MA re-enrollment, and whether this association is modified by Alzheimer's Disease and Related Dementias (ADRD), prior nursing home use, chronic illness, dual eligible status, and availability of MA plans and quality. Not applicable. Overall, 3.3% of beneficiaries switched to MA annually. Of those with prior MA enrollment, MA switching percentages were 9.0%, 4.6%, and 6.8% for those whose most recent MA enrollments were 1, 2, and 3 years prior to their baseline FFS year. Comparatively, the switching percentages was 3.2% for those with no prior MA enrollment. The hazards of switching to MA were 2.73 (p < 0.001), 1.29 (p < 0.001), and 1.97 (p < 0.001) times greater than remaining in FFS for beneficiaries whose most recent MA enrollments were one, two, and three years prior to their baseline FFS year. Hazards of switching were generally similar between those with and without ADRD, stratified by recency in prior MA experience, except those with dual eligibility. Among those with ADRD, switching hazards were greatest for 3 years prior MA enrollees in counties with the fewest available (HR: 3.84, p < 0.001) and lowest-rated plans (HR: 4.02, p < 0.001). Recency of switching from MA to FFS was the strongest predictor of a FFS-to-MA switch, identifying a population of beneficiaries who multiply switch regardless of health status or MA access. Future health policy considerations should more closely examine the vulnerabilities and long-term outcomes of this population.

Progression from Non-alcoholic Steatohepatitis to Advanced Liver Diseases and Mortality Among Medicare Patients.

Non-alcoholic steatohepatitis (NASH) may progress to more advanced liver disease. This study aimed to characterize NASH progression and mortality in the Medicare population. Patients with NASH in 100% Medicare fee-for-service claims accrued from2015-2021 who were≥66years old at index diagnosis, continuously enrolled for≥12months prior to and≥6months following index (unless death), and had no evidence of other causes of liver disease were included. Diagnosis codes defined severity states: non-cirrhotic NASH, compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), and liver transplant (LT). Survival analyses of disease progression and mortality were conducted for each state and by year of progression (Y1-5). Cox proportional hazards models assessed risk factors of worsening disease. Mean age and follow-up were 72.2 and 2.8years in 14,806 unique patients (n=12,990 NASH; 1899 CC; 997 DCC; 209 HCC; 140 LT). Progression rates were highest for patients with CC (11-37% for Y1-5), followed by DCC (3-18%), NASH (3-12%), and HCC (2-4%). Mortality rates were highest for patients with HCC (41-85% for Y1-5), followed by DCC (41-76%), LT (7-33%), CC (6-26%), and NASH (2-12%). Patients with any disease progression had a 5-year mortality rate more than double that of patients without progression (41% vs. 16%). Delayed progression from NASH was associated with lower mortality risk; the 5-year mortality rate was 26% lower for patients with progression in Y2 vs. Y1 (32% vs. 43%) and further decreased for progression in Y3-Y5. Risk factors included age, nursing home use, congestive heart failure, coagulopathy, fluid/electrolyte disorders, and unexplained weight loss. Medicare patients≥66years with NASH experience high risk of disease progression associated with increased mortality rates. Slower disease progression is associated with lower mortality rates, suggesting that therapies that can delay or prevent NASH progression may reduce morbidity and mortality.

THE EFFECT OF GERMANY’S LONG-TERM CARE STRENGTHENING ACT II ON NURSING HOME USE

Abstract In Germany, out-of-pocket costs for nursing home care have substantially increased during the last years. There is an ongoing discussion whether these out-of-pocket costs should be capped. However, a decrease in costs may increase nursing home use and the social costs of nursing home care. This study analyzes how a change in out-of-pocket costs for nursing home care affects nursing home use. We use discontinuities in out-of-pocket costs that arose from Germany’s Long-Term Care Strengthening Act II in 2017. The Long-Term Care Strengthening Act II decreased average nursing home care costs for people with higher care needs and increased average costs for people with lower care needs. Long-term care insurance data are analyzed using a regression discontinuity design. There is no significant change in nursing home use among people who enter long-term care with relatively high care needs. However, there is a significant decrease in nursing home use among those who enter long-term care with relatively low care needs. The results are robust regarding different specifications of the model. We conclude that the elasticity of nursing home use depends on the level of care needs. For people with high care needs, nursing home care is often without alternatives, whereas people with lower care needs may substitute nursing home care with informal care. A generous public policy does not necessarily increase demand for nursing home care.

CHANGES IN LONG-TERM CARE ARRANGEMENTS AMONG OLDER ADULTS WITH ADRD DURING THE FIRST YEAR OF THE COVID-19 PANDEMIC

Abstract This study will examine how COVID-19 affected care needs and immediate long-term care (LTC) outcomes including paid and family care, coresidence with adult children, and nursing home use for older adults living with ADRD. For this study we use the 2018 and 2020 waves of the Health and Retirement Study (HRS), a longitudinal, nationally representative survey of individuals aged 51 and older in the U.S. To assess how long-term care arrangements changed among older adults with dementia during the first year of the COVID-19 pandemic, we first describe the needs and LTC outcomes of older adults living with dementia and examine changes between 2018 and 2020 comparing them to changes among older adults with care needs but no dementia. Then, to identify changes associated with COVID-19 (rather than secular trends due to disease progression) we compare the 2020 LTC outcomes of HRS respondents with care needs who had differential exposure to the severity of the pandemic. We proxy pandemic severity with county level COVID-19 deaths. To understand whether changes in LTC outcomes among older adults with dementia were different from the broader population of high-need older adults, we interact local COVID-19 severity with the presence of dementia in 2018. Preliminary findings indicate a retreat from paid care and increases in coresidence with adult children and receiving unpaid help but no significant differences in LTC outcomes among high need older adults with and without dementia.

Read It Three Times, Then Read It Again: How Nursing Homes Use "Responsible Party" Clauses in Admission Agreements to Charge Relatives for Their Loved Ones' Care.

This Note explores an alarming, decades-old trend that has received renewed attention from enforcement agencies and the media: nursing homes suing family members and friends ("relatives") for residents' unpaid bills. As justification, nursing homes point to "responsible party" clauses within admission agreements signed by relatives during the admission process. Undeterred by the 1987 Federal Nursing Home Reform Act's (FNHRA) prohibition on requiring relatives to act as financial guarantors in exchange for residents' admission, nursing homes use carefully worded "responsible party" clauses to obtain virtually the same result: relatives' total liability for residents' unpaid balances. Relatives are frequently caught off-guard by these lawsuits; many who sign admission agreements do so without a proper understanding of the potential liability they are assuming and have limited (if any) access to residents' assets. This problem is aggravated by several aspects of the admission process that disadvantage relatives, such as the stressful and emotional nature of admission, the complicated language in admission agreements, and the inadequate-at times, misleading-guidance provided by nursing homes. This Note examines the tension between the FNHRA's financial protections for relatives and nursing homes' admission practices and use of "responsible party" clauses. Furthermore, this Note proposes solutions aimed at better informing relatives of the legal risks associated with "responsible party" clauses.

Neuropsychiatric symptoms are Predictors of Disturbed Sleep in Mexican American Caregivers

AbstractBackgroundCaregivers of people living with dementia are more likely to experience disturbed sleep compared to non‐caregivers. Mexican‐Americans may be especially at risk due to low rates of nursing home use even in advanced dementia, when behavioral symptoms are most apparent. Few studies have evaluated predictors of disturbed sleep in this high‐risk group.MethodUsing data from the 2015 wave of the Hispanic Established Population for Epidemiologic Study of the Elderly, a representative sample of older Mexican‐Americans and their caregivers in the southwestern United States (n = 460), we examined the association of care recipient neuropsychiatric symptoms with disturbed sleep in caregivers. Care recipients’ behavioral symptoms of cognitive decline were assessed using the caregiver‐reported Neuropsychiatric Inventory. We examined caregivers’ depressive symptoms as an additional stressor. Potential “buffers” against sleep disturbances included communal support (neighbor, church, social services) and respite care. Caregivers were classified as having “highly disturbed sleep” if they reported disturbed sleep three or more days a week, and were compared to caregivers with “non‐highly disturbed sleep” (reported disturbed sleep less than three days a week). We used multivariable logistic regression to examine the association between behavioral symptoms and highly disturbed sleep, controlling for demographic factors and care buffers.ResultCaregivers in the sample were predominantly spouses or adult children of their care recipients. They had a mean age of 59.7 and7 8% were women. Care recipients were a mean age of 90 and 65% were women. Caregivers with disturbed sleep (12% of the sample) reported significantly more care recipient NPI symptoms, distress from symptoms, and more depressive symptoms. In the regression model accounting for all predictors, the number of NPI symptoms and depressive symptoms were associated with higher odds of disturbed sleep, while communal support was associated with lower odds of disturbed sleep. Use of respite care did not show associations.ConclusionBehavioral symptoms of cognitive impairment are associated with sleep disturbance in Mexican American caregivers. Though respite has been described as a crucial resource for caregiver sleep health, communal supports were more significantly associated with sleep l. These results should inform the development of culturally‐competent resources for Mexican‐Americans.

Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life.

Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.

Hospital Discharge to Nursing Homes and Antibiotic Use

Hospital Discharge to Nursing Homes and Antibiotic Use

Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic

Staffing shortages have been widely reported in US nursing homes during the COVID-19 pandemic, but traditional quantitative research analyses have found mixed evidence of staffing shortfalls. To examine whether nursing home administrator perspectives can provide context for conflicting aggregate staffing reports in US nursing homes during the COVID-19 pandemic. In a qualitative study, convergent mixed-methods analysis integrating qualitative and quantitative data sets was used. Semistructured qualitative interviews were conducted between July 14, 2020, and December 16, 2021. Publicly available national Payroll Based Journal data were retrieved from January 1, 2020, to September 30, 2022, on 40 US nursing homes in 8 health care markets that varied by region and nursing home use patterns. Staffing and resident measures were derived from Payroll Based Journal data and compared with national trends for 15 436 US nursing homes. Nursing home administrators were recruited for interviews. Of the 40 administrators who consented to participate, 4 were lost to follow-up. Four repeated, semistructured qualitative interviews with participants were conducted. Interview questions focused on the changes noted during the COVID-19 pandemic in nursing homes. Thematic description of nursing home administrator compensatory strategies to provide context for quantitative analyses on nursing home staffing levels during the COVID-19 pandemic. A total of 156 interviews were completed with 40 nursing home administrators. Administrators reported experiencing staff shortages during the COVID-19 pandemic and using compensatory strategies, such as overtime, cross-training, staff-to-resident ratio adjustments, use of agency staff, and curtailing admissions, to maintain operations and comply with minimum staffing regulations. Payroll Based Journal data measures graphed from January 1, 2020, to September 30, 2022, supported administrator reports showing that study facilities had reductions in staff hours, increased use of agency staff, and decreased resident census. Findings were similar to national trends. In this qualitative, convergent mixed-methods study, nursing home administrators reported the major staffing strain they experienced at their facilities and the strategies they used to offset staffing shortages. Their experiences provide context to quantitative analyses on aggregate nursing home census data. The short-term compensatory measures administrators used to comply with regulations and maintain operations may be detrimental to the long-term stability of this workforce.

Association of Social Isolation With Hospitalization and Nursing Home Entry Among Community-Dwelling Older Adults

Social isolation is associated with adverse health outcomes, yet its implications for hospitalization and nursing home entry are not well understood. To evaluate whether higher levels of social isolation are associated with overnight hospitalization, skilled nursing facility stays, and nursing home placement among a nationally representative sample of community-dwelling older adults after adjusting for key health and social characteristics, including loneliness and depressive symptoms. This observational cohort study included 7 waves of longitudinal panel data from the Health and Retirement Study, with community-dwelling adults aged 65 years or older interviewed between March 1, 2006, and June 30, 2018 (11 517 respondents; 21 294 person-years). Data were analyzed from May 25, 2022, to May 4, 2023. Social isolation was measured with a multidomain 6-item scale (range, 0-6, in which a higher score indicates greater isolation). Multivariate logistic regressions were performed on survey-weighted data to produce national estimates for the odds of self-reported hospitalization, skilled nursing facility stays, and nursing home placement over time. A total of 57% of this study's 11 517 participants were female, 43% were male, 8.4% were Black, 6.7% were Hispanic or Latino, 88.1% were White, 3.5% were other ("other" includes American Indian or Alaska Native, Asian or Pacific Islander, and other race, which has no further breakdown available because this variable was obtained directly from the Health and Retirement Study), and 58.2% were aged 65 to 74 years. Approximately 15% of community-dwelling older adults in the US experienced social isolation. Higher social isolation scores were significantly associated with increased odds of nursing home placement (odds ratio, 2.01; 95% CI, 1.21-3.32) and skilled nursing facility stays (odds ratio, 1.16; 95% CI, 1.06-1.28) during 2 years. With each point increase in an individual's social isolation score, the estimated probability of nursing home placement or a skilled nursing facility stay increased by 0.5 and 0.4 percentage points, respectively, during 2 years. Higher levels of social isolation were not associated with 2-year hospitalization rates. This cohort study found that social isolation was a significant risk factor for nursing home use among older adults. Efforts to deter or delay nursing home entry should seek to enhance social contact at home or in community settings. The design and assessment of interventions that optimize the social connections of older adults have the potential to improve their health trajectories and outcomes.

Changes in Nursing Home Use Following Medicaid-Supported Expanded Access to Home- and Community-Based Services for Older Adults With Dementia

New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care. To evaluate changes in nursing home use among older adults with dementia following MLTC implementation. This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019. Mandatory MLTC enrollment. Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators. This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year). The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

Medicaid home and community-based services spending for older adults: Is there a "woodwork" effect?

Although older adults prefer to age at home, Medicaid has a longstanding institutional bias in funding long-term services and supports (LTSS). Some states have resisted expanding Medicaid funding for home- and community-based services (HCBS) due to budgetary concerns related to the so-called "woodwork" effect whereby individuals enroll on Medicaid to access HCBS. To examine the implications associated with state Medicaid HCBS expansion, we obtained state-year data for 1999-2017 from various sources. We estimated difference-in-differences regressions comparing outcomes in states that expanded Medicaid HCBS aggressively versus those that expanded less aggressively, controlling for several covariates. We examined a range of outcomes including Medicaid enrollment, nursing home census, Medicaid institutional LTSS spending, total Medicaid LTSS spending, and Medicaid HCBS waiver enrollment. We measured HCBS expansion by the total share of state Medicaid LTSS spending for aged and disabled persons devoted to HCBS. HCBS expansion was not associated with increased Medicaid enrollment among individuals ages 65 and older. A 1% increase in HCBS spending was associated with reductions in the state nursing home population of 47.1 residents (95% confidence interval [CI]: -80.5, -13.8) and institutional Medicaid LTSS spending of $7.3 million (95% CI: -$12.1M, -$2.4M). A $1 increase in HCBS spending was associated with $0.74 increase (95% CI: $0.57, $0.91) in total LTSS spending, suggesting each dollar directed to HCBS was offset by $0.26 savings from decreased nursing home use. Increased HCBS waiver spending was associated with more older adults receiving LTSS at a lower cost per beneficiary served relative to the nursing home setting. We did not find evidence of a woodwork effect in those states that expanded Medicaid HCBS more aggressively, as measured by age 65 and older Medicaid enrollment. However, they did experience Medicaid savings from reduced nursing home use, suggesting states that expand Medicaid HCBS are able to use these additional dollars to serve more LTSS recipients.

Rural disparities in use of family and formal caregiving for older adults with disabilities.

As federal and state policies rebalance long-term care from institutional settings to home- and community-based settings, reliance on formal (paid) and family (unpaid) caregivers for support at home nationally has increased in recent years. Yet, it is unknown if use of formal and family care varies by rurality. Using the Health and Retirement Study, we describe patterns in receipt of combinations of formal and family home care and self-reported expectation of nursing home use by rurality among community-dwelling adults aged 65+ with functional limitations from 2004 to 2016. Older adults residing in rural areas are more likely to receive any family care than those in urban areas. From 2004 to 2016, a higher proportion of older adults in rural areas receive care from family caregivers exclusively while a lower proportion receive care from formal caregivers exclusively. When examining older adults in urban areas, we find the opposite - a higher proportion of urban adults rely exclusively on formal care and a lower proportion rely exclusively on family care in 2016 compared to 2004. We find that national estimates of sources of caregiving and their changes over time mask significant heterogeneity in uptake by rurality. Understanding how older adults in rural areas are, or are not, receiving home-based care compared to their urban peers and how these patterns are changing over time is the first step to informing supports for family and formal caregivers.

Urinary L-Type Fatty Acid-Binding Protein Predicts Oxygen Demand of COVID-19 in Initially Mild Cases.

To predict COVID-19 disease severity within 10 days, distinguishing cases that will progress to moderate or severe versus mild, patient urinary L-type fatty acid-binding protein (L-FABP) was assayed within 4 days of receiving a diagnosis. The study also examined whether L-FABP point of care (POC) test is helpful in risk screening. Symptomatic subjects who tested positive for SARS-CoV-2 and were hospitalized were prospectively enrolled at the National Center for Global Health and Medicine (NCGM), Yamanashi Prefectural Central Hospital (YPCH), and Sinai Hospital in Maryland. The outcome of each case was evaluated 7 days after admission and the diagnostic performance of L-FABP was assessed. Subjects were treated for COVID-19 at public healthcare centers in Japan from January 31, 2020, to January 31, 2021, to NCGM, YPCH, and at Sinai Hospital in Baltimore, MD, during the same period. The primary outcome was to determine whether urinary L-FABP within 48 hours of admission can predict the patient's severity of COVID-19 1 week later. We obtained demographic data, information on clinical symptoms, radiographic images, and laboratory data. Diagnostic performance was assessed using receiver operating characteristic analysis. Of the 224 participants in the study, 173 initially had a mild form of COVID-19. The area under the curve (AUC) for a severe outcome was 93.5%. L-FABP POC risk prediction of a severe outcome had an AUC of 88.9%. Urinary L-FABP can predict patient risk of COVID-19 illness severity. L-FABP POC is implementable for patient management. (ClinicalTrials.gov number, NCT04681040).

Risk of Discharge to Lower-Quality Nursing Homes Among Hospitalized Older Adults With Alzheimer Disease and Related Dementias

Individuals with Alzheimer disease and related dementias (ADRD) frequently require skilled nursing facility (SNF) care following hospitalization. Despite lower SNF incentives to care for the ADRD population, knowledge on how the quality of SNF care differs for those with vs without ADRD is limited. To examine whether persons with ADRD are systematically admitted to lower-quality SNFs. Cross-sectional analysis of Medicare beneficiaries hospitalized between January 1, 2017, and December 31, 2019, was conducted. Data analysis was performed from January 15 to May 30, 2022. Participants were discharged to a Medicare-certified SNF from a general acute hospital. Patients younger than 65 years, enrolled in Medicare Advantage, and with prior SNF or long-term nursing home use within 1 year of hospitalization were excluded. The quality level of all SNFs available at the patient's discharge, measured using publicly reported 5-star staffing ratings. The 5-star ratings were grouped into 3 levels (1-2 stars [reference category, low-quality], 3 stars [average-quality], and 4-5 stars [high-quality]). The outcome was the SNF a patient entered among the possible SNF destinations available at discharge. Differences in the association between SNF quality and SNF entry for patients with and without ADRD were assessed using a conditional logit model, which simultaneously controls for differences in discharging hospital, residential neighborhood, and the other characteristics (eg, postacute care specialization) of all SNFs available at discharge. The sample included 2 619 464 patients (mean [SD] age, 81.3 [8.6] years; 61% women; 87% were White; 8% were Black; 22% with ADRD). The probability of discharge to higher quality SNFs was lower for patients with ADRD. If the star rating of an SNF was high instead of low, the log-odds of being discharged to it increased by 0.31 for patients with ADRD and by 0.47 for those without ADRD (difference, -0.16; P < .001). The weaker association between quality and entry for patients with ADRD indicates that they are less likely to be discharged to high-quality SNFs. The findings of this study suggest that patients with ADRD are more likely to be discharged to lower-quality SNFs. Targeted reforms, such as ADRD-specific compensation adjustments, may be needed to improve access to better SNFs for patients with ADRD.

Nursing Home Use of a Resident and Family Decision Guide to Reduce Hospital Readmissions: A Quality Improvement Project

This article presents a quality improvement project involving the first organizational-level test of the effectiveness of a new U.S. Centers for Medicare and Medicaid Services (CMS) endorsed Decision Guide, Go to the Hospital or Stay Here? A Decision Guide for Residents, Families, Friends, and Caregivers. This Decision Guide can enhance resident and family knowledge about nursing home (NH) capabilities and is intended to reduce nursing home resident and family insistence on potentially unnecessary resident transfers and hospital readmissions. The SQUIRE 2.0 guidelines were the framework for this project. A quality improvement project was conducted in 16 NHs in the southeastern United States to evaluate the effect of the resident and family Decision Guide on hospital readmission rates. Prior to implementation, the investigators provided an online orientation to the project followed by onsite training of nursing home personnel. The NHs then distributed and reviewed the Guide with residents and their family members. NH staff entered data related to readmissions and resident and family responses to the Guide into a secure portion of the project website. NH staff recorded data for three months before Guide implementation and for three months after Guide distribution. Three of the nursing homes lost their upper management team soon after study initiation and were unable to continue. A fourth did not provide complete data. In the 12 remaining facilities, the three-month mean number of readmissions dropped from 27 pre-intervention to 18.58, a 31.2% decrease. Participating facilities reported the Guide was very well received by residents and their families. The facilities’ personnel reported that most residents and family members were unaware of the scope of services provided by the nursing home, an information gap filled by the Decision Guide. They found that implementing this Guide in nursing homes was cost-effective, easy to use, and could substantially reduce readmissions. The results of this quality improvement project demonstrated a significant decrease in hospital readmission rates underscoring its potential for quality improvement in NH care and avoidance of burdensome hospital transfers.

DEMENTIA TRAJECTORIES, MEDICAID COVERAGE, AND HEALTHCARE SERVICES USE

Abstract The evidence base linking dementia risk trajectories to transitions in Medicaid coverage and levels of health services is underdeveloped. We use Health and Retirement Study (2007/08-2015/16) data on adults 70-years and older (Unweighted N=8,227) at baseline to test how longitudinal dementia classifications (Langa-Weir), over 8-years, influence change in Medicaid coverage, nursing-home use (NHU) and inpatient hospitalizations (IH). We fit Joint Growth and Discrete-time Survival Mixture models to generate longitudinal risk classifications for dementia accounting for survival, and generalized linear models to test associations of these classifications with change in Medicaid coverage, NHU, and IH. Average baseline age was 78.4 years (SD=7.1), 3-in-5 were female, 1-in-4 had less than high school education, and 4-in-5 were non-Hispanic Whites. A three-class solution (C1=high dementia prevalence and mortality risk (8.6%), C2=low prevalence (68.3%), and C3=accelerated dementia prevalence and mortality risk (23.1%)) provided the best fit to the data. We observed substantial increase in rates of for Medicaid coverage for C1 (21%; 95%CI=[18-25] to 51%[36-65] among survivors) and C3 (12%; 95%CI=[10-14] to 32%[27-37]), but not C2 (6% to 8%). NHU also accelerated substantially from 10 to 37% in C1 and 7 to 38% in C2. Rates of inpatient hospitalizations remained stable over time for all groups, with C1 and C2 being more likely to be hospitalized and have multiple re-admissions. Estimates were differentially attenuated through adjustment to covariables. We report important longitudinal dementia risk classifications, profile their socioeconomic and health attributes, and identify differential associations with critical health policy outcomes (Medicaid coverage and healthcare utilization).

ADDRESSING UNMET LONG-TERM SERVICES AND SUPPORTS NEEDS FOR RACIAL/ETHNIC MINORITY OLDER ADULTS

Abstract The COVID-19 pandemic magnified several long-standing problems with the delivery of long-term services and supports, including access to care in the community setting. A disproportionate rise in nursing home use among Black and Latino older adults reflects the inadequacy of existing programs and policies to support aging in place for these most at-risk populations. Enabling aging in the community and preventing avoidable nursing home placements is widely considered a priority by federal, state, and local entities along with families and older adults. Yet, it is unclear what is needed to support Black and Latino older adults to remain in the community. In this presentation, Dr. Travers will discuss unmet long-term services and supports needs among the Black and Latino population, issues particularly faced by these populations during COVID-19, and opportunities to move forward as we transition to an 'endemic' COVID-19 landscape.

Nursing Home Residents Younger Than Age Sixty-Five Are Unique And Would Benefit From Targeted Policy Making.

Existing public policies often fail to acknowledge differences between older (ages sixty-five and older) and younger (younger than age sixty-five) people with disabilities residing in nursing homes. We compared long-stay (over sixty days) residents across age groups and then documented state-level variation in their age-adjusted prevalence in 2019 and trends in prevalence during the period 2013-19. Compared with older residents, younger residents tended to have different diagnoses and were more likely to reside in for-profit and lower-quality facilities, as well as to be non-White and male. Among younger people with disabilities, nursing home use varied widely across states, and trends in use were only weakly correlated with trends for older adults. Although rates of state-level nursing home placement among older adults generally declined, in many states they stagnated or grew among those younger than age sixty-five, with no convergence of trends in placement across states. Our findings suggest the value of approaching younger people with disabilities as a distinct population. We offer targeted policies to divert these people from nursing homes to home and community-based settings.

Minority Older Adults’ Access to and Use of Programs of All-Inclusive Care for the Elderly

ABSTRACT Programs of All-Inclusive Care for the Elderly (PACE) are an effective approach to improve care quality and delay institutional admissions especially for Black and Hispanic older adults who have seen a disproportionate rise in nursing home use. Guided by Andersen’s Behavioral Model of Health Services Use and employing focus groups and one-on-one interviews, we qualitatively examined factors influencing access to and use of PACE by Black and Hispanic older adults. The study sample consisted of thirty-two PACE enrollees, six marketing-team members, and four family-caregivers from three PACE sites in a northeast urban city. Informed knowledge, cultural beliefs, and attitudes toward PACE were found to affect access. Community resources, available services, and care quality facilitated enrollment/participation. Barriers identified included poor dissemination of information and inadequate emphasis on staff’s sensitivity to enrollees’ cultural and disability differences. Findings will help healthcare leaders capitalize on facilitators and address barriers to enhance access and use of PACE by racial and ethnic minority older adults.