Use Of Long-term Services Research Articles

GOAL ATTAINMENT SCALING IN CAPABLE: A COMPARISON OF CARE PARTNER AND OLDER ADULT PARTICIPATION

Abstract Aging in place is an optimal outcome for our maturing population as health systems become increasingly overburdened. One program that facilitates aging in place is the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program. CAPABLE improves older adult performance in everyday activities and reduces inpatient and long-term service use. Although CAPABLE is designed as a person-centered program aiming to help older adults set and achieve goals, research demonstrates that care partners (i.e. family or friends providing unpaid support) are frequently involved in healthcare decisions and can reinforce intervention goals. This presentation will report findings from the trial stage of a Hybrid Type 1 Study of CAPABLE involving care partners for which recruitment is ongoing (N=100). We aim to describe how older adults and their care partners engage in goal setting using Goal Attainment Scaling, share the frequency of their goal attainment, and present the types of goals that they set. For example, older adult participant goals for our current sample focus on reduced fear when showering, improved mobility, and more efficient dressing. For our care partner participants, goals include finding respite and preventing older adult injury. All participants who have completed CAPABLE were able to achieve their goals by the end of the program. Findings from this study support care partner involvement in interventions to promote aging in place, aligning with the RAISE Act’s goal to engage family caregivers as key partners in the delivery of services and support.

REBALANCING LONG-TERM CARE: THE ROLE OF MEDICAID-MANAGED LONG-TERM SERVICES AND SUPPORTS

Abstract From 2018 to 2020, Pennsylvania conducted a phased implementation of a mandatory Medicaid managed long-term services and supports program called Community HealthChoices (CHC). The new program covers people receiving Medicaid financed long-term services and supports (LTSS) in nursing homes and home and community-based settings. The three participating MCOs are incentivized to serve people in the community. This study took advantage of the phased implementation to generate causal estimates of the effect of the new program on both the extensive margin (the proportion of people receiving HCBS vs. nursing homes), and the intensive margin (the type and amount of HCBS services). Medicaid claims data for the years 2013 to 2020 were analyzed to examine pre-program trends and program effects. There was a long-term pre-program trend away from nursing homes. The implementation of managed care did not appear to accelerate this trend, however, analysis of data from 2020 is complicated by the COVID-19 pandemic. However, MLTSS did appear to control to growth in hours of personal care per person both in the aggregate and longitudinally within the same individuals over time. There were decreases in the use of adult day services and home delivered meals. However, the decline in home delivered meals was more than offset by an increase in uptake of the supplementary nutritional assistance program (SNAP). This is the first causal analysis of the effects of managed care on use of long-term services and supports. The findings have implications for other states that are considering implementing similar policies.

Use of long-term services and supports among dual-eligible beneficiaries with Alzheimer's disease and related dementias.

To respect people's preference for aging in place and control costs, many state Medicaid programs have enacted policies to expand home and community-based services as an alternative to nursing facility care. However, little is known about the use of Medicaid long-term services and supports (LTSS) at a national level, particularly among dual-eligible beneficiaries with Alzheimer's disease and related dementias (ADRD). Using Medicare and Medicaid claims of 30 states from 2016, we focused on dual-eligible beneficiaries 65 years or older with ADRD and described their use of any form of LTSS and sub-types of LTSS (home-based, community-based, and nursing facility services) across states. We found that 80.5% of dual-eligible beneficiaries with ADRD received some form of Medicaid LTSS in 2016. The most common LTSS setting was nursing facility (46.7%), followed by home (31.5%) and community (12.2%). There was sizeable state variation in the percentage of dual-eligible beneficiaries with ADRD who used any form of LTSS (ranging from 61% in Maine to 96% in Montana). The type of LTSS used also varied widely across states. For example, home-based service use ranged from 9% in Maine, Arizona, and South Dakota to 62% in Oregon. Nursing facility services were the most common type of LTSS in most states. However, home-based service use exceeded nursing facility use in Oregon, Alaska, and California. Our findings suggest substantially different use of LTSS across states among dual-eligible beneficiaries with ADRD. Given the importance of LTSS for this population and their families, a deeper understanding of state LTSS policies and other factors that contribute to wide state variation in LTSS use will be necessary to improve access to LTSS across states.

Access and Barriers to Use of Long Term Services: Contextual Issues

The challenges that some older adults face in accessing both health and social services is a topic of continuing concern. This panel will focus on contextual issues that often shape specific challenges. These contextual issues usually emerge either from issues of diversity among the older persons themselves (for example, minority status or foreign born) and diversity between the ways in which services are offered (usually established at the national or in the case of the United States, at the state level). The intersection of these two forms of diversity often define the specific challenges faced by older persons in accessing health and social services. Further, unexpected events, such as the COVID pandemic, can affect both types of diversity (greater challenges for persons who do not speak the dominant language; inability of services to quickly adapt to radically changed environment). Our panel will address these issues through four presentations, each taking a different look at the ways in which diversity affects access. Our first paper, by Torres, will place this discussion in wider context by presenting results from a scoping review. Our second paper, by Diederich looks at access to services by immigrant generation (that being another source of diversity) in Germany. The third paper, by Thiamwong looks at how the COVID crisis affected older Hispanic women. Finally, Ring will examine how a national policy, here the definition of poverty, affects outcome and access for older person in the United States.

Using Population-Level Data to Assess Need for and Use of Long-Term Services and Supports in California

In response to aging and disability stakeholder advocacy in California, the state’s 2018-19 budget included support for the development of a study of Californians with needs for long-term services and supports (LTSS). Existing data on LTSS most typically represents those who already use specific programs or services. Yet many programs do not uniformly collect and report data, or have little capacity to share data across different delivery systems. In response to these gaps, we developed a 15-minute follow-on survey to the 2019-2020 California Health Interview Survey (CHIS), gathering statewide population-level data to assess LTSS needs and use by Californians 18 years of age and older. This paper reports on preliminary findings from the 2019 CHIS-LTSS survey conducted with a sample of 1097 respondents. Screening questions identified respondents reporting difficulties with concentrating, remembering, or making decisions (60%), performing basic daily activities such as dressing or bathing (26%), or getting out of the house to shop or to see the doctor (52%). Nearly half of respondents (45%) reported needing help with routine care needs while 16% needed help with personal care needs. Additional findings illustrate specific LTSS needs, service use, consequences of unmet needs, financial concerns, and consumer experiences. At a time when California policy makers, program planners, and advocates are engaged in implementing a 10-year Master Plan for Aging, these findings can be used to identify and address gaps in the types of services and supports that are essential to meet the LTSS needs of older adults and people with disabilities.

Long-term Service Use Among Youths Previously Treated for Anxiety Disorder

(1) To describe rates of long-term service use among subjects previously enrolled in a landmark study of youth anxiety disorder treatment and followed into early adulthood; (2) to examine predictors of long-term service use; and (3) to examine the relationship between anxiety diagnosis and service use over time. The Child/Adolescent Anxiety Multimodal Extended Long-term Study prospectively assessed youths treated through the Child/Adolescent Anxiety Multimodal Study at ages 7-17 years into early adulthood. A total of 319 youths (mean age 17.7, 55.2% female) previously randomized to cognitive-behavioral therapy, sertraline, combination, or placebo for the treatment of anxiety participated; 318 had service use data. Four annual clinic assessments were conducted along with telephone check-ins every 6 months. Overall, 65.1% of participants endorsed receiving some form of anxiety treatment over the course of the follow-up period, with more subjects reporting medication use than psychotherapy; 35.2% reported consistent use of services over the course of the study. Overall, service use declined over time in subjects with less severe anxiety but remained more steady in those with recurrent/chronic symptoms. Levels of life stress and depressive symptoms were associated with amount of service use over time whereas treatment-related variables (type of initial intervention, acute response, remission) were not. A subset of youths remained chronically anxious despite consistent service use. These findings point to the need to develop models of care that approach anxiety disorders as chronic health conditions in need of active long-term management.

Adapting Andersen\u2019s expanded behavioral model of health services use to include older adults receiving long-term services and supports

BackgroundAndersen’s Expanded Behavioral Model of Health Services Use describes factors associated with the use of long-term services and supports (LTSS). This model, however, has only been tested on the intent to use such services among African-American and White older adults and not the actual use. Given the increasing diversity of older adults in the U.S., the ability to conceptualize factors associated with actual use of LTSS across racial/ethnic groups is critical.MethodsWe applied Andersen’s Expanded model in the analysis of 2006–2010 qualitative data using multiple methods to understand both the relevancy of factors for older adults who currently use LTSS vs. those who intend to use LTSS (as described in Andersen’s original exploration). We additionally explored differences in these factors across racial/ethnic groups and included Hispanic older adults in our analyses.ResultsFour additional constructs linked with actual LTSS use emerged: losses and changes, tangible support, capability to provide informal support, and accessibility of informal support. Racial differences were seen in level of participation in decisions to use nursing home services (Not involved: 45% African-Americans vs. 24% Whites). Reports of LTSS use to avoid burdening one’s family were greater among White older adults compared to African-American older adults.ConclusionsFindings around decision-making and burden along with other constructs enhance our understanding of determinants that influence actual LTSS use and require targeted interventions.

Centre-based supervised child-parent contact in Ireland: The views and experiences of fathers, supervisors and key stakeholders

The paper presents findings from a study of centre-based supervised child-parent contact. The purpose of the research was twofold: to ascertain the views and experiences of birth fathers on all aspects of the supervised child-parent contact they experienced in a centre; and to find out from centre supervisors their views of engaging fathers and supervising contact, and from key stakeholders and referral agents (a community project worker, a child protection social worker, Guardians ad Litem and a family law solicitor) their perceptions of the supervised contact provision in the centre. Interviews with five fathers having supervised child-parent contact and three focus group discussions with seven staff members and six stakeholders were undertaken. While the study is exploratory, the findings show that gender is a feature meriting consideration in the supervised child parent contact setting; and that child-centred values, family-centred values and the demands of operating the centre are held in tension so that the purpose and scope of supervised contact can be interpreted and experienced differently. While optimal supervised child -parent contact is generally perceived as a short-term arrangement, there was some evidence of long-term service use, which was a significant issue for the fathers concerned. The fathers valued relationship-based supervision practice to a greater extent than the supervisor and stakeholder participants, who put greater emphasis on skills required for supervision. Fathers expressed concerns about what they or their children can say or do during contact visits in view of how it may be observed, interpreted and reported. The findings suggest the need for a gender-sensitive approach in supervision practice; the value of a common framework for assessing what is observed in contact visits; and the intensification of strategies to facilitate and to recognise progress and the prioritisation of short term supervised contact arrangements with the required supports.

Distributional Effects of Alternative Strategies for Financing Long-Term Services and Supports and Assisting Family Caregivers

We use two historical data sources – the Health and Retirement Study and the Medicare Current Beneficiary Study – to consider the patterns in older Americans’ severe disability and their use of long-term services and supports (LTSS) by age and socioeconomic status. We then use a dynamic microsimulation model to project how the effects of various interventions to support those with severe disabilities and their caregivers would be distributed across the income distribution. The interventions that we examine fall into three broad classes: tax credits for caregiving expenses, respite care for people in the community with family caregivers, and new social insurance programs. Within each broad class of policies, we examine how sensitive outcomes are to changes in policy details (such as, in the case of tax credits, deductible levels, refundability, and income phase-outs). This paper found that: • Older adults with less education and less wealth are more likely to report disabilities and service use than their more educated and wealthier counterparts. • This pattern persists when we look at people at a point in time but also, more robustly, when we look at their disabilities prospectively. In a sample of older adults who do not report disabilities at baseline, we find that those with fewer economic resources earlier in life are generally more likely to develop disabilities and use paid LTSS over the next two decades, but the differences narrow when we restrict the sample to people who do not develop disabilities until their late 70s. The policy implications of this paper are: • The uneven distribution of disability risks across the population poses challenges for developing effective LTSS policies. Those most likely to need LTSS often lack enough resources to contribute to LTSS programs, and programs that try to contain costs by using underwriting or imposing work requirements often disqualify those who most need coverage. • Certain classes of policies, such as respite care benefits, tend to direct much of their benefits to those in lower income quintiles, according to our projections. Caregiver tax credits and social insurance programs generally distribute benefits more proportionally, although impacts vary depending on how the policies are specified. • Policy design details can significantly affect distributional outcomes. Provisions’ effects can be sensitive to the stacking order in which they are implemented. • It can be useful to examine trends and proposals not only cross-sectionally but also over longer time periods. For example, the distributional effects of social insurance programs depend on the relatively high early-life mortality of those with less education and lower earnings and wealth.

Expectations about future use of long-term services and supports vary by current living arrangement.

Most Americans know little about options for long-term services and supports and underestimate their likely future needs for such assistance. Using data from the 2012 National Health Interview Survey, we examined expectations about future use of long-term services and supports among adults ages40-65 and how these expectations varied by current living arrangement. We found differences by living arrangement in expectations about both future need for long-term services and supports and who would provide such care if needed. Respondents living with minor children were the least likely to expect to need long-term services and supports and to require paid care if the need arose. In contrast, respondents living alone were the most likely to expect that it was "very likely" that they would need long-term services and supports and to rely on paid care. Overall, we found a disconnect between expectations of use and likely future reality: 60percent of respondents believed that they were unlikely to need long-term services and supports in the future, whereas the evidence suggests that nearly 70percent of older adults will need them at some point. These findings both underscore the need for programs that encourage people to plan for long-term services and supports and indicate that information about living arrangements can be useful in developing and targeting such programs.

Payment rates for personal care assistants and the use of long-term services and supports among those dually eligible for Medicare and Medicaid.

To examine the association between payment rates for personal care assistants and use of long-term services and supports (LTSS) following hospital discharge among dual eligible Medicare and Medicaid beneficiaries. State hospital discharge, Medicaid and Medicare claims, and assessment data on California Medicaid LTSS users from 2006 to 2008. Cross-sectional study. We used multinomial logistic regression to analyze county personal care assistant payment rates and postdischarge LTSS use, and estimate marginal probabilities of each outcome across the range of rates paid in California. We identified dual eligible Medicare and Medicaid adult beneficiaries discharged from an acute care hospital with no hospitalizations or LTSS use in the preceding 12 months. Personal care assistant payment rates were modestly associated with home and community-based services (HCBS) use versus nursing facility entry following hospital discharge (RRR 1.2, 95 percent CI: 1.0-1.4). For a rate of $6.75 per hour, the probability of HCBS use was 5.6 percent (95 percent CI: 4.2-7.1); at $11.75 per hour, 18.0 percent (95 percent CI: 12.5-23.4). Payment rate was not associated with the probability of nursing facility entry. Higher payment rates for personal care assistants may increase utilization of HCBS, but with limited substitution for nursing facility care.

Length of first admission and treatment outcome in patients with unipolar depression

BackgroundUnipolar depression is among the most common reasons for psychiatric hospitalisation. But only few studies focussed on inpatient treatment and its impact on short- or long-term outcome in these patients. Thus, we studied as to what extent patients with unipolar depression use psychiatric inpatient resources, and examined whether the length of stay is associated with short-term improvement and rehospitalisation. Finally, we analysed if there is an ‘optimal’ length of first hospitalisation. MethodsIn a catchment area in Switzerland, psychiatric inpatient utilisation over 5 years was analysed in 458 first-ever admitted patients with unipolar depressive disorder (ICD-10, F32 and F33). Results365 patients (79.7%) were admitted only once. Patients with a first inpatient stay of 15–30 days had the shortest cumulative length of further inpatient treatment. Symptom improvement during first hospitalisation was immediately linked to the length of stay (first and further episodes) and to a regular discharge from first admission. Higher symptom improvement predicted shorter length of stay and less rehospitalisations. Demographic (age, gender, employment, living situation) and clinical variables (dual diagnosis, one or multiple episodes of unipolar depression, illness severity) did not significantly influence short-term outcome and long-term service use. LimitationsThe study is biased towards the more severely ill as we only included inpatients. ConclusionsVariables describing the first hospitalisation of patients with unipolar depression are more appropriate for clinical prognosis than sociodemographic or diagnostic factors. Moreover, improving clinical symptoms is more important for long-term outcome than the length of inpatient stay.

128 Fretting Fatigue Behavior in the Ultra High Cycle Regime

Research on fatigue behavior in the ultra high cycle regime has been recently focused since the fatigue mechanism and S-N behavior different from those observed less than (10)^7 cycles have been observed. It is also of importance from the viewpoint of the long-term service use of structures and machines. Limited research works have been available on fretting fatigue in the ultra high cycle regime, while lots of studies have been done on plain fatigue even in this regime. In the present study, a new machine for ultra high cycle fatigue test has been developed with an electro-magnetic vibrator. It was confirmed that fretting fatigue strength, lives, frictional force and relative slip amplitude were not significantly influenced by the cyclic loading rate up to 300 Hz, which was the present test condition for ultra high cycle fretting fatigue. The fretting fatigue strengths defined at (10)^7 cycles were effective up to (10)^8 and (10)^9 cycles for titanium alloy and aluminum alloy. The fretting fatigue crack initiated at the end region of fretting contact area even in the ultra high cycle regime, which indicated that the fatigue mechanism would not change even in the ultra high cycle regime. This might result from the singular stress field near the contact edge in fretting fatigue.