Use Of Community-based Services Research Articles

Dementia Care in Rural Appalachia: Multilevel Analysis of Individual and County-level Factors.

Home- and community-based services (HCBS) are underutilized, despite offering significant health benefits to both care recipients and caregivers. Drawing upon Andersen's extended behavioral model of health services use, we examined individual and county-level factors influencing HCBS utilization for dementia care in rural Appalachia. We analyzed data from telephone interviews with 123 dementia family caregivers in rural Appalachian counties (Mage = 64.7, SDage = 12.2). Multilevel analyses were conducted to examine the effects of individual-level and county-level factors on the use of home-based services (home health care and personal care services) as well as community-based services (adult day care and transportation services). Results indicated that caregivers' receipt of informal support from family or friends were associated with more use of home-based services (B = 0.42, p = 0.003). Conversely, longer travel times to service providers were linked to use of fewer community-based services (B = -0.21, p < .001). Residing in counties with more home health agencies was associated with higher utilization of home-based services (B = 0.41, p = 0.046). However, higher county tax expenditures for HCBS were not linked to home-based or community-based service use. Findings suggest that informal support in caring for the person living with dementia enables HCBS use in rural Appalachia. In contrast, limited geographic accessibility and service availability can impede HCBS use in rural regions. Policymakers are urged to allocate direct public funding to service providers to expand service availability in under-resourced rural regions.

Community resource facilitation use by ethnic minority groups with traumatic brain injury in the Midwestern United States

ABSTRACT Objective This study surveyed the use of community-based resource facilitation (RF) services by ethnic minority survivors of traumatic brain injury (TBI) living in the Midwestern United States. Method Past records of RF use by survivors of TBI were reviewed. Demographics and patterns of RF use across 3 ethnic groups were documented. Reported barriers to community integration related to ethnic identity were identified using Chi-square test of independence. Results Ethnic minority survivors were less likely to use RF services than white survivors. Caucasian women and men utilized RF services at similar rates, whereas more African American men and Latina women used RF services. Caucasians received information about RF from a greater variety of sources than ethnic minority survivors. Ethnic identity was significantly associated with greater reported needs for TBI awareness. Conclusions A pattern of differential RF use by survivors from ethnic minority groups was noted, suggesting potential socio-cultural influences on help-seeking behavior after TBI. These factors should be considered to develop more accessible and equitable strategies of RF service referral and support. Future investigations of cultural perspectives of TBI and injury-related services may improve understanding of the likelihood and necessity of community-based RF service use by diverse populations.

Factors associated with use of community-based, peer-led sexual and reproductive health services by adolescent boys and young men aged 18-24 in Lusaka, Zambia: A case control study nested in the Yathu Yathu trial.

Adolescents and young people (AYP) aged 15-24 years have the least access to facility-based sexual and reproductive health (SRH) services, including HIV services. The Yathu-Yathu cluster-randomized trial (CRT) in Zambia tested whether a novel peer-led community-based approach increased knowledge of HIV status amongst AYP. In this nested case-control study, we aimed to identify factors associated with non-attendance to the Yathu Yathu hubs by adolescent boys and young men (ABYM) aged 18-24-years. Yathu Yathu was a CRT conducted in two communities in Lusaka, Zambia, with 10 intervention and 10 control zones. AYP in all zones were offered prevention points cards (PPC), which incentivized and tracked service use at the hubs and health facility. In intervention zones, services were provided to AYP through community-based spaces (hubs) led by peer support workers. In these zones, cases were defined as those not having accessed any service at a hub and controls as those that accessed at least one service. Data were collected from October 2020 to January 2021 and analysed using methods appropriate for unmatched case-control studies. 161 cases and 160 controls consented to participate in the study. Participants aged 20-24 years (adjOR 1.99, 95%CI 1.26-3.12, p = 0.003), who were educated up to college level (adjOR 8.47,95%CI 2.08-34.53, p = 0.001) or who reported being employed in the last 12 months (adjOR 2.15, 95%CI 1.31-3.53, p = 0.002) were more likely to not attend the hubs. ABYM who had a friend with a PPC were more likely to attend the hubs (adjOR 0.18 95%CI 0.09-0.35, p<0.001). Most cases reported having their last HIV test at the local government health facility (58%) while most controls reported HIV-testing at a Yathu Yathu hub (82%). Among the controls, 84% (134/160) rated the hub experience as excellent. Among cases, 65% (104/161) stated they didn't visit the hubs "due to employment". Despite Yathu Yathu services being community-based and more accessible compared to health facilities, we found age, education and employment were associated with not attending hubs. Strategies are needed to reach employed young men who may not have access to SRH/HIV services during conventional working hours and to better utilise peer networks to increase service use.

Use of home and community-based services and loneliness in older people with functional limitations: a cross-sectional study

BackgroundLoneliness is one of the major health problems among older adults. Among this population, home and community-based services (HCBS) have become increasingly popular. Despite its health benefits, little is known about the relationship between HCBS use and loneliness in older people with functional limitations. We aim to explore the characteristics of loneliness among older people with functional limitations and examine the association between HCBS use and loneliness in China.MethodsWe used a cross-sectional data from the 2018 China Health and Retirement Longitudinal Study, which includes a nationally representative sample of Chinese residents aged 65 and older with functional limitations. Logistic regression models were used to examine the associations between HCBS use and loneliness, and we further used propensity score matching to address potential sample selection bias.ResultIn China, 46% of older people with functional limitations felt lonely and only 22% of older people with functional limitations reported using HCBS in 2018. Compared with participants who did not receive HCBS, those who received HCBS were less likely to report loneliness (OR = 0.81, 95% CI = 0.63, 0.99, p = 0.048), and the results remained significant after addressing sample selection bias using propensity score matching.ConclusionOur results showed that loneliness was common among Chinese older people with functional limitations, and the proportion of HCBS use was low. There was robust evidence to support that among older people with functional limitations, HCBS use was associated with decreased loneliness. Further policies should promote the development of broader HCBS use for older people with functional limitations to reduce their loneliness.

Home and Community-Based Service Use Varies by Health Care Team and Comorbidity Level of Veterans with Dementia

ABSTRACT Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients’ type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients’ non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

Effect of enhanced nutrition services with community-based nutrition services on the diet quality of young children in Ethiopia.

Poor diet quality related to inadequate complementary feeding is a major public health problem in low and middle-income countries including Ethiopia. Low dietary diversity has been linked to negative health outcomes in children. To provide a package of interventions to close nutritional gaps through agriculture, the Sustainable Undernutrition Reduction in Ethiopia (SURE) programme was set up as a multi-sectoral initiative and the results of combined effects of community-based and enhanced nutrition services, compared to community-based alone, on diet diversity and diet quality of complementary feeding of young children are presented. The study used pre- and post-intervention design. Baseline (n = 4980) data were collected from May to July 2016, and follow-up (n = 2419) data from December 2020 to January 2021. From 51 intervention districts having the SURE programme, 36 intervention districts were randomly selected for baseline and 31 for the follow-up survey. The primary outcome was diet quality: minimumdietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD). Comparing endline to baseline over the 4.5-year intervention, the use of standard community-based nutrition services of growth monitoring and promotion increased (16%-46%), as did enhanced nutrition services of infant and young child feeding counselling, and agricultural advising (62%-77%). Women involved in home gardening significantly increased (73%-93%); however, household production of food decreased yet consumption of most own-grown foods increased. Importantly, MAD and MDD increased four-fold. TheSURE intervention programme was associated with improvements in complementary feeding and diet quality through enhanced nutrition services. This suggests programmes targeted at nutrition-sensitive practices can improve child feeding in young children.

Community-Based Service Use After Clozapine Treatment: A Mirror-Image Analysis of Public Claims Data.

Although clozapine demonstrates unique efficacy for treatment-resistant schizophrenia, its impact on community-based services remains largely underexplored. The authors examined changes in use of community-based services after clozapine treatment among a sample of 163 patients with schizophrenia by using public claims data in Allegheny County, Pennsylvania. Mirror-image analyses of service utilization were used to compare the 180-day period before treatment initiation with the 180-day period that began after 6 months of adherent treatment, accounting for age, race, and gender. Across demographic variables, clozapine treatment was associated with increased use of community-based services and decreased use of psychiatric inpatient services (p<0.05, Bonferroni corrected), suggesting that clozapine treatment shifts service needs from emergency care to community-based care and recovery.

The Effect of Community Health Information System on Health Care Services Utilization in Rural Ethiopia.

In Ethiopia, the community health information system (CHIS) is implemented at the health post (hp) level with the aim of improving service delivery and use. We conducted a national level assessment of CHIS utilization and explored the associations of CHIS utilization with use of antenatal care (ANC), postnatal care (PNC), institutional delivery and child immunization in rural Ethiopia. We conducted a cross-sectional study measuring community-based health service use and HP based CHIS assessment from March to May 2019. Data were collected from 343 HPs and 2,864 women who delivered in the last five years, and multistage sampling was used to select the study subjects. We used descriptive statistics for CHIS implementation and service utilization and multilevel logistic regression to investigate the association of CHIS implementation with maternal and child health care services use. Fifty five percent of the HPs were implementing CHIS. These HPs were using a paper-based household data collection tool called family folder (FF). Of the HPs, one third implemented lot quality assurance sampling (LQAS) based data quality check and 60.4% documented and followed execution of decisions. Overall, among the eligible women, 40% used ANC, close to 50% of currently married women used ANC services; 28% of women that fall in the high wealth index category used PNC within 48 hours after delivery; and 86.1% of women who had at least a high school education delivered at a health facility. Implementation of CHIS and family folder utilization and conducting LQAS based data quality check in the HPs were significantly associated with increased odds of ANC, delivery, and vaccination services use. We found that better implementation of CHIS was associated with better maternal and child health service use which implies that increasing utilization of CHIS at HPs will improve mother and child health service use.

Use of Home and Community-Based Services After Implementation of Medicaid Managed Long Term Services and Supports in Virginia

ABSTRACT Many state Medicaid programs contract with managed care organizations to deliver long-term services and supports (LTSS) to seniors and persons with disabilities. Managed LTSS (MLTSS) programs are often intended to increase access to and utilization of home- and community-based services (HCBS), yet there are few empirical studies of their effects. In this retrospective observational study, we used administrative data from Virginia Medicaid to compare HCBS waiver enrollment and service utilization pre- and post-implementation of MLTSS. Compared to the prior fee-for-service system, Medicaid beneficiaries with long-term care needs who were enrolled in Virginia’s MLTSS program were more likely to be enrolled in Virginia’s 1915(c) waivers for home and community-based services. Further, the likelihood of using personal care increased by nearly 5%, and the likelihood of using respite care increased by about 10%. These findings are pertinent to ongoing policy changes that use private managed care organizations to deliver long-term services and supports to seniors and persons with disabilities. Policymakers in states and the federal government should note these initial increases in service use under Medicaid MLTSS, while supporting evaluations of the long-term impacts of MLTSS on HCBS use and beneficiary health and satisfaction.

Vigilance, risk, and service use among caregivers of people living with dementia.

The purpose of this investigation was to understand the dynamics among dementia caregiving, vigilance, and home and community-based service use. This paper is derived from a larger, mixed-methods study on caregiving. We used a descriptive qualitative approach to analyze interview data of 30 family caregivers of relatives with dementia. We found five domains of vigilance in which caregivers felt "on duty": ensuring attentiveness, ensuring safety, ensuring resources, ensuring healthcare, and ensuring closeness. Formal service use did not necessarily give caregivers relief from vigilance, with the language of risk often employed by caregivers. Because service use could contribute to feelings of vigilance, rather than give caregivers a break from a sense of watchfulness, these findings support calls for dementia-specific training for service providers. In future caregiving research, the relationship between vigilance, caregiver distress, and role captivity should be explored.

MISSION AND VISION OF THE MULTISITE VA ELIZABETH DOLE CENTER OF EXCELLENCE (EDCOE) FOR VETERAN AND CAREGIVER RESEARCH

Abstract Enabling Veterans to remain safely in their homes is a Department of Veterans Affairs (VA) priority. Informal caregivers play a critical role in supporting Veterans with functional impairments through their own efforts and the use of home and community-based services (HCBS). The Elizabeth Dole Center of Excellence (EDCoE) for Veteran and Caregiver Research was created in 2018 as part of the VA Choose Home Initiative to expand VA capacity to deliver integrated, Veteran- and caregiver-partnered, data-driven approaches to care through a set of complimentary projects. The EDCoE is a virtual center, with its multi-disciplinary team spread across the country at 5 different VA Medical Centers. The team also collaborates with other VA caregiver researchers. Finally, the EDCoE is closely networked with national, regional, and local operational partners, allowing for rapid dissemination of findings. In this symposium, we will first discuss the mission and vision of the EDCoE. We will then discuss multiple projects that are led through the EDCoE. Paper 1 (San Antonio) will identify measurement gaps to guide monitoring and improving HCBS. Paper 2 (Miami/Canandaigua) will describe a national survey of 8000+ Veterans and 3500+ caregivers. Paper 3 (Palo Alto) will describe caregivers’ barriers to accessing VA and non-VA HCBS. Paper 4 (Salt Lake City/Canandaigua) will describe the results of latent trajectory analyses of administrative data to identify groups of Veterans who use different combinations of HCBS and institutional services. Our results are used by VA operational partners and policymakers to improve services for Veterans and informal caregivers.

DEMENTIA FAMILY CAREGIVERS EXPERIENCES USING COMMUNITY-BASED AND HEALTHCARE SERVICES DURING COVID-19

Abstract Family caregivers are key medical decision makers for persons living with dementia (PLwD) and play a critical role in interfacing with community-based services and the health care system. The COVID-19 pandemic, however, had dramatic impact on service utilization, with many suspended, delayed, or moved to telehealth. Emerging data suggests the pandemic posed challenges to service use for family caregivers, yet how this impacted caregiver’s care practice is unknown. An in-depth qualitative interview was conducted with 100 primary family caregivers for PLwD in 2021 on care management during the COVID-19 pandemic. Watkins’ rigorous and accelerated data reduction technique was used to analyze qualitative data through open and focused coding and identify themes specific to family caregiver’s access to and use of community-based and health care services. Themes emerged regarding challenges and benefits of service use during the pandemic. Caregivers struggled with not being allowed to attend medical appointments with the PLwD or to speak confidentially with the physician over a PLwD’s telehealth appointment. Caregivers felt physicians couldn’t always read the care situation over telehealth, but appreciated not having to leave the house. Losing the consistency of in-home caregivers or respite programs put additional strain on caregivers, but many found virtual programming engaging. Grocery delivery/pickup was a new service used by many caregivers and found to be supportive of in-home care. As the pandemic evolves, finding ways to support caregivers through continued involvement in health care visits and as they access community services is critical to caregiver and PLwD health and well-being.

IMPLEMENTATION AND IMPACT OF MANAGED LONG-TERM SERVICES AND SUPPORTS IN PENNSYLVANIA

Abstract In 2018, Pennsylvania began implementing a mandatory Medicaid managed care program called Community HealthChoices (CHC). CHC replaces the 1915(c) aging waiver and 4 other waiver programs that covered adults with disabilities and people with acquired brain injury. The new program covers people receiving long-term services and supports (LTSS) in both nursing homes and home and community-based settings as well as people dually eligible for both Medicaid and Medicare. The program is administered by 3 managed care organizations (MCOs) that are obligated to coordinate with Medicaid Behavioral Health, Medicare Advantage and D-SNP plans. The MCOs are incentivized to serve people with LTSS needs in community-based settings by increasing access to HCBS and supporting transitions from nursing homes back into the community. This symposium will present findings from a comprehensive, mixed-methods evaluation of the program. Drawing from our qualitative interviews with key stakeholders and examination of program materials, we will describe some of the challenges of the implementation process. Next, we will share findings from interviews with cohorts of participants conducted before and after implementation of the new program. Next, we will present findings from analysis of Medicaid claims data to examine changes in use of home and community-based services as well as overall rebalancing. Finally, we will present both qualitative and quantitative data on person-centered service planning- a critical requirement for HCBS programs.

Effect of different patterns of home- and community-based services in Taiwan on the changes in physical function.

Our study aimed to explore the impact of different home- and community-based service (HCBS) use patterns on older adults' physical function. The cohort data were drawn from two national datasets, the National Ten-Year Long-Term Care Plan 1.0 database and the National Health Insurance Program claims data. Participants were care recipients ages 65 and over, first evaluated and prescribed HCBS from 2010 through 2013 and evaluated again after 6 months (n=32,392). Latent class analysis was used to identify subgroups with different HCBS use patterns. Multiple regression was used to examine the impact of different HCBS use patterns on change over time in disability related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The analysis was stratified by respondents' levels of disability. Four subgroups of HCBS recipients were identified, with patterns of home-based personal care, home-based personal care and medical care, home-based medical care and community care services. Older adults in the Home-based MpC had significantly more improvement in both ADL (p < 0.05) and IADL (p < 0.001) scores compared with adults in the other three groups, while the community care group regressed the most. In the stratified analysis of the severely disabled, the IADL outcome of the Home-based MC group was better than the home-based PC group (p < 0.001). Study findings shed light on the benefits of promoting the use of integrated HCBS that combines personal and medical care, especially for community care services.

Duration of Dementia and Social Service Use in the U.S.-Born and Foreign-Born Mexican-American Population.

The study estimates the number of years after age 65 that Mexican Americans live with likely dementia and the impact of dementia on community-based services (CBS) use by nativity. Using the Hispanic Established Populations for the Epidemiologic Studies of the Elderly Sullivan methods are employed to predict duration of dementia and logistic regressions identify the predictors of service utilization. Foreign-born women spend more years than other groups with dementia. The foreign-born are more likely to use out-of-home services, whereas U.S.-born are more likely to use in-home services. The foreign-born with dementia of relatively recent onset had the highest probability of service use. Given the high cost of institutional care and availability of family caregivers, community-based services are a potentially useful alternative for the growing Mexican-American population living with dementia. Expanded Medicaid and CBS programs could be an equitable and cost-effective alternative that should be investigated.

Continuing chronic care services during a pandemic: results of a mixed-method study

BackgroundPatients with chronic diseases have seen unprecedented changes to healthcare practices since the emergence of COVID-19. Traditional ‘on-site’ clinics have had to innovate to continue services. Whether these changes are acceptable to patients and are effective for care continuation are largely unreported.MethodsWe evaluated the effectiveness of care provision at a re-structured chronic care clinic and elicited the patient experiences of care and self-management. We conducted a convergent, parallel, mixed-methods study. Adult patients attending a chronic care clinic were included. We extracted data from 4,849 clinic visits before and during the COVID-19 pandemic, including operational metrics and attendee profile. We also conducted fifteen interviews with patients from the same clinic using a semi-structured interview guide.ResultsRe-structuring the chronic clinic, including the introduction of teleconsultations, home-delivery of prescriptions and use of community-based phlebotomy services, served to maintain continuity of care while adhering to COVID-19 containment measures. Qualitatively, five themes emerged. Patients were able to adjust to healthcare practice changes and adapt their own lifestyles, although poor self-management practices were adopted. While most were apprehensive about attending the clinic, they valued ongoing care access and were reassured by the on-site containment measures.ConclusionsContinuation of routine services is desired by patients and can be achieved through the adoption of containment measures, by greater collaboration with community partners, and the use of technology. Patients adapted to service changes, but poor self-management was evident. To prevent chronic disease relapse, services must strive to innovate rather than suspend services during pandemics.

Trends In Medicaid Home And Community-Based Services Waivers For Older Adults.

During the past several decades, state Medicaid programs have expanded the use of home and community-based services, particularly through Section 1915(c) waivers and Section 1115 demonstration waivers. We document trends from the period 1997-2020 in waivers targeting older adults, focusing on services offered. Nearly every service category saw an increase in coverage and spending, especially support for self-direction and community transition.

Why do older adults living alone in cities cease seeking assistance? A qualitative study in China

BackgroundAgainst the background of an aging population, older adults living alone in cities are increasingly dependent. However, their use of home and community-based services in China is unsatisfactory. This study attempted to figure out why older adults living alone in cities do not actively seek assistance in China.MethodsIn-depth interviews were conducted. A total of 29 older adults were recruited. Content analysis was used to analyze the interview data.ResultsThree themes were identified. (1) Desire for independence, despite hardship: The lives of older adults involve many inconveniences, but they preferred to solve problems by themselves, instead of asking for help; (2) Desire to not overburden jiaren (meaning family in Chinese): older adults did not want to disturb families or burden children with caring responsibilities. Moreover, previous experience of failing to obtain care made them reluctant to seek help from jiaren; (3) Desire to not bother wairen (meaning people other than family in Chinese): The lack of trust caused by being unfamiliar with wairen, and the fear of being a burden to others if they were not able to reciprocate, made older adults reluctant to seek help from wairen.ConclusionsChanges in social, economic, and demographic structures have led to gradual failure of family care. Older adults accustomed to an “acquaintance society” have not yet adapted to seeking help from the community. When addressing the problem of care for older adults living alone in cities, it is important to focus on the profound impact of social change.

Patterns of Home and Community Based Service Use by Beneficiaries Enrolled in the Pennsylvania Medicaid Aging Waiver.

This study examines multiple services are used across a population and the association between type and amount of services use with level of disability and living arrangement. This is a descriptive cross-sectional analysis examining HCBS use among older Pennsylvanians from 2014 to 2016 enrolled in Pennsylvania's 1915(c) waiver program. Data were derived from Medicaid claims. Logistic regression and OLS regression were used to examine the association between service use and level of disability, controlling for age, gender, race, and other covariates. People with Alzheimer's or a related dementia were more likely to use adult day care. People with higher ADL and IADL limitations were more likely to use higher amounts of PAS and less likely to have delivered meals. These findings demonstrate HCBS is a complex package of services that are allocated regarding the level of need and resources available to individual program participants.

A Systematized Approach to Advancing the Quality of Community-Based Palliative Care.

Despite growing recognition of the importance of community-based palliative care, optimizing the use of services continues to be a challenge. Until recently, key barriers were reimbursement and limited access. As services have become increasingly available, engagement of patients and their caregivers has emerged as a major obstacle. The Palliative Activation SystemTM (PAS) is a comprehensive, quality improvement methodology designed to promote enhanced engagement of seriously ill adults and their caregivers in optimizing the use of community-based palliative care services and accelerate clinicians' progress in meeting patients' and caregivers' care goals. This paper describes the design of the PAS. Experts in patient engagement and the development and evaluation of palliative care programs advised organizational leaders in the development of this methodology. The "Patient and Family Engagement" framework proposed by Carman and colleagues (2013) guided this work. The framework informed the selection of three core concepts-care alignment, illness trajectory, and social determinants of health-as foundational to the goals of the PAS. Additionally, this framework guided the selection of measures that will be used to assess progress in achieving enhanced engagement. This background work, coupled with findings from interviews with patients and caregivers who are current recipients of palliative care services, resulted in the implementation and ongoing testing of strategies targeting clinicians and organizational leaders and designed to enhance engagement. Lessons learned from the design phase of the PAS will advance the efforts of other organizations committed to increasing patient and caregiver engagement and enhancing attainment of their goals.