Adverse Consequences of Unmet Needs for Care in High-Need/High-Cost Older Adults

Assistive device utilization among disabled elderly in China: A cross-sectional study

OBJECTIVE

This study aimed to examine the characteristics of assistive device users and influencing factors among disabled elderly in China.

METHODS

A total of 13,510 disabled elderly in Sichuan Province were surveyed. Disability was assessed using the Barthel Activities of Daily Living Scale, mental status, sensory perception, and social engagement evaluation. Univariate analysis and logistic regression analysis were employed to identify the impact factors.

RESULTS

The prevalence of assistive device utilization among participants was 79.2% (10,700/13,510, 95% CI 78.5%-79.9%), with the wheelchair being the most commonly used device. Various factors were found to influence the usage of the device, including disability level, somatic disability, age, caregivers, income, caregiver fees, and living situation (p < .05). Additionally, several factors were identified associated with the frequency of device usage, such as somatic disability, education background, income, caregiver fees, living situation, access to acquire assistive devices, duration of assistive device usage, education on assistive devices, and satisfaction level (p < .05).

CONCLUSIONS

The use of assistive devices among elderly individuals in China is prevalent. There are many factors that affect the use of assistive devices, which can provide a reference for the formulation of policies in the field of assistive devices.

The Consequences of Unmet Needs for Assistance With Daily Life Activities Among Older Adults: A Systematic Review

Many older adults are experiencing unmet needs for assistance with the activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Such unmet needs might threaten their physical and psychosocial well-being. We conducted a systematic review to provide a comprehensive picture of the health consequences of unmet ADL/IADL needs among older adults. Twenty-eight published articles were included for qualitative synthesis. We found that unmet ADL/IADL needs were consistently associated with higher health care utilization (e.g., hospitalization, medical spending) and adverse psychosocial consequences (e.g., anxiety, depression), while the findings of falls and mortality remain inconsistent. More studies are needed to draw firm conclusions and to allow for quantitative synthesis. This review advocates for more coordinated and comprehensive long-term care services for older adults. Future studies should explore how the adverse health outcomes identified in this review can be prevented or improved by adequately meeting older adults' needs for assistance.

Transitions across states with and without difficulties in performing activities of daily living and death: a longitudinal comparison of ten European countries

Ageing has been related to the onset of disability and dependency in older adults. There is a need to better understand the disability and dependency trajectories of older adults and their relationship with socio-demographic characteristics and institutional or cultural context. This study analyses the role of age, sex, education and self-perceived health in disability, dependency and death transitions, addressing the heterogeneity across European countries and inconsistencies when using different measures of disability. Multi-state models were adjusted to evaluate the role of risk and protective factors in the transitions to disability, dependency and death. Difficulties in performing activities of daily living (ADLs) assess disability and dependency states. Data were from the Survey of Health, Ageing and Retirement in Europe conducted in 2004-2013, considering individuals aged 65 and older at baseline from Austria, Belgium, Denmark, France, Germany, Italy, the Netherlands, Spain, Sweden and Switzerland. The results showed that transitions to disability and dependency varied with age, sex, education and self-perceived health. The probability of transition to disability and dependency states increases until the age of 70 for all countries. However, there was heterogeneity in the disability and dependency trajectories with ageing between men and women. In most countries, women live with difficulties and may need help for longer than men. Care policies should consider sex differences to decrease the burden of care of informal caregivers, particularly in countries where care systems are absent or partially developed and a high level of family obligations to care needs exist.

Impact of diagnosed (vs undiagnosed) dementia on family caregiving experiences

BACKGROUND

Most older adults with Alzheimer's disease and related dementias (ADRD) do not receive a timely formal diagnosis, although formal diagnosis is linked to improved outcomes. Little is known about how a recognized formal diagnosis impacts family caregivers, who provide crucial support for older adults experiencing ADRD.

METHODS

We analyzed 2017 National Health and Aging Trends Study and linked National Study of Caregiving data for a nationally representative sample of 724 (weighted n = 5,431,551) caregivers who assisted an older adult with probable dementia. Probable dementia was determined via previously validated composite measure. We modeled caregiver experiences as a function of recognized formal ADRD diagnosis using weighted, logistic regression and adjusting for the relevant older adult and caregiver characteristics.

RESULTS

Among caregivers who assisted an older adult with probable dementia, those assisting an individual with recognized formal ADRD diagnosis were significantly more likely to report emotional difficulty (aOR: 1.77; p = 0.03) and family disagreement over the older adult's care (aOR: 5.53; p = 0.03). They were also more likely to assist with communication during doctors' visits (aOR: 9.71; p < 0.001) and to receive caregiving-related training (aOR: 2.59; p = 0.01).

CONCLUSIONS

While a timely ADRD diagnosis may help ensure access to needed supports for older adult and caregiver alike, diagnosis must be linked to support as they navigate resultant complex emotions. Formal diagnosis is linked to caregiver integration with, and support from, the older adult's team of health care providers; therefore, reducing existing disparities in timely diagnosis is necessary to ensure all caregivers have equal access to support.

Intergenerational Day Centers: A New Wave in Adult and Child Day Care

Intergenerational Day Centers (IDCs) are an innovation that addresses two important societal challenges, the continuing need for childcare and the emerging demand for older-adult supportive services that help them remain independent in their homes. These facilities provide care, and specialized resources and activities for both older adults and children in one location. While the importance and benefits of these programs have been proven, there is scant information in the literature and best-practice guidelines on the planning and development of these programs. This qualitative study focuses on the research, planning, and building development for new IDCs in metropolitan areas. It is based on a case example of the process of establishing an IDC in the City of Austin, which was an element of the Age-Friendly Austin Plan. It examines the applicable literature and the extensive involvement of experts in architecture, community planning, and public health policy as well as data collected from community engagement workshops to facilitate the IDC's creation and operation. This study offers a developmental strategy method that can be adopted and utilized by other cities, developers, and designers who are interested in building IDCs.

Latent dependency classes according to the need for help: a population-based analysis for the older population

Background

Older adults living in the community may have daily needs for help to perform different types of activities. In developing countries, older adults face the additional challenge of lacking sufficient economic means to face their increasing needs with ageing, and health and social policies may be under pressure. The aim of this study was to assess dependency in the older population from a developing country using a latent class approach to identify heterogeneity in the type of activities in which dependent older adults require help.

Methods

In this cross-sectional evaluation of dependency, we considered individuals aged 60 years and older from a nationally representative study (N = 5138) in Uruguay. We fitted latent class regressions to analyse dependency, measured by the need for help to perform Activities of Daily Living, adjusted by sociodemographic characteristics.

Results

Four latent classes were identified, 86.4% of the individuals were identified as non-dependent, 7.4% with help requirements to perform instrumental activities while individuals in the other two classes need help to perform all types of activities with different degrees (4.3 and 1.9%). Less educated women are more likely to be in the group with needs in instrumental activities.

Conclusions

The heterogeneous patterns of dependency have to be addressed with different services that meet the specific needs of dependent older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03307-w.

Detecting Risk of Neglect in NSHAP Round 3 Using New Follow-Up Questions to Activities of Daily Living Measures

OBJECTIVES

Elder neglect is a type of elder abuse wherein an older adult's basic needs remain unmet through negligence. The risk of neglect and its harmful consequences coincides with the need for care that arises with difficulties completing activities of daily living (ADLs) and instrumental activities of daily living (IADLs). In this paper, we describe how new questions included in Round 3 (2015-2016) of the National Social Life, Health, and Aging Project (NSHAP-R3) can help detect the risk of elder neglect.

METHODS

Based on the 2,340 respondents who indicated problems with at least one ADL or IADL, we categorized respondents as at a higher risk of neglect if they were either: (a) not getting wanted help (WANTHELP) or (b) getting help from an undependable caregiver (UNRELIABLE). We tested the external validity of these indicators by examining their association with NSHAP-R3 measures of physical and mental health, personal hygiene, home tidiness, social support, and elder mistreatment, using t tests and chi-square tests.

RESULTS

Those labeled higher neglect risk based on the WANTHELP variable showed significantly worse self-rated physical health, personal hygiene, room tidiness, mental health, partner support, family support, and elder mistreatment. The same correlates were significantly associated with higher neglect risk based on the UNRELIABLE variable, except for self-rated physical health, personal hygiene, and room tidiness.

DISCUSSION

Findings suggest that these new measures can be useful for identifying NSHAP respondents who are at risk of types of neglect that can be associated with having I/ADL limitations.

Effect of Practicing Health Behaviors on Unmet Needs among Patients with Chronic Diseases: A Longitudinal Study

With the growing prevalence of chronic diseases, the proportion of unmet needs is increasing. In this study, we investigated the effect of practicing health behaviors on unmet needs among patients with chronic diseases, using data from the Korea Health Panel Survey conducted between 2014–2017. Participants (n = 4069) aged 19 or older, with at least one chronic disease (hypertension, diabetes mellitus, dyslipidemia, or arthrosis) and with existing follow up data were selected. Health behaviors combined three variables: not presently smoking, not belonging to high-risk drinking group, and indulging in moderate- or high-intensity exercise. Those who met all three criteria were classified as the practicing health behaviors group. Generalized Estimating Equation analysis was performed to consider correlated data within a subject. Of the participants, 23.9% practiced health behaviors. Participants who did not practice health behaviors were significantly more likely to have unmet needs compared with those who did (OR: 1.24, 95% CI: 1.10–1.39). Further research would be needed to verify the impact of practicing health behavior on unmet needs.

What Does "Patient-Centered" Mean? Qualitative Perspectives from Older Adults and Family Caregivers

This study aimed to (1) examine what patient-centeredness means for older adults and family caregivers, and (2) assess circumstances underlying their preference for geriatric care. We conducted separate focus groups with older adults and family caregivers of older adults about health care experiences and expectations and conducted a vignette-based experiment to assess preference for geriatric care. Participants expressed a need for greater skill and empathy and integration of caregivers. They preferred geriatric care to usual primary care with increasing social, health, and healthcare complexity. Distinct needs of older adults should be considered in referral practices to geriatric medicine.

Disparities in Preventable Hospitalization Among Patients With Alzheimer Diseases

INTRODUCTION

System-level care coordination strategies can be the most effective to promote continuity of care among people with Alzheimer's disease; however, the evidence is lacking. The objective of this study is to determine whether accountable care organizations are associated with lower rates of potentially preventable hospitalizations for people with Alzheimer's disease and whether hospital accountable care organization affiliation is associated with reduced racial and ethnic disparities in preventable hospitalizations among patients with Alzheimer's disease.

METHODS

This study employed a cross-sectional study design and used 2015 Healthcare Cost and Utilization Project inpatient claims data from 11 states and the 2015 American Hospital Association Annual Survey. Logistic regression and the Blinder-Oaxaca decomposition method were used.

RESULTS

African American patients with Alzheimer's disease were less likely to be hospitalized at accountable care organization‒affiliated hospitals than White patients. Among patients with Alzheimer's disease who were hospitalized, hospital accountable care organization affiliation was associated with lower odds of potentially preventable hospitalizations (OR=0.86, p=0.02; OR=0.66, p<0.001 with propensity score matching) after controlling for patient characteristics, hospital characteristics, and state indicators. Hospital accountable care organization affiliation explained 3.01% (p<0.01) of the disparity in potentially preventable hospitalizations between White and African American patients but could not explain disparities between White and Latinx patients.

CONCLUSIONS

Evidence suggests that accountable care organizations may be able to improve care coordination for people with Alzheimer's disease and to reduce disparities between Whites and African Americans. Further research is needed to determine whether this benefit can be attributed to accountable care organization formation or whether providers that participate in accountable care organizations tend to provide higher-quality care.

Clustering Complex Chronic Patients: A Cross-Sectional Community Study From the General Practitioner's Perspective

Objective:

Characterize subgroups of Complex Chronic Patients (CCPs) with cluster analysis from the general practitioner’s perspective.

Study design:

Cross-sectional population-based study.

Setting:

Three Primary Care urban centres for a reference population of 43,647 inhabitants over 14 years old in Sabadell, Catalonia, Spain.

Methods:

Complexity is defined by the independent clinical judgment of general practitioners with the aid of complexity domains (both clinical and social). We used a Two-Step Cluster method to identify relevant subgroups of CCPs.

Results:

Three relevant subgroups were identified. The first one was mainly managed by primary care professionals, and 63% of its CCPs belonged to the high-risk stratum of the Adjusted Morbidity Groups (GMA). The second subgroup included younger patients than the other two clusters, and showed the highest ratios of social deprivation and severe mental disease; 48% of its CCPs belonged to the high-risk stratum of the GMA. A third cluster included patients who belonged to the high-risk stratum of the GMA. Their age was similar to that of the patients in the first cluster, but they showed the highest values in the following areas: (i) risk of admission; (ii) proportion of advanced chronic disease and limited-life prognosis; (iii) functional loss and (iv) geriatric syndromes, along with special uncertainty in decision-making and clinical management.

Conclusions:

Characterization of CCPs shows clearly distinct profiles of needs, which provides an improved epidemiological picture by identifying clusters of patients who are likely to benefit from targeted interventions.

Family Caregiving for Older Adults

Family members are the primary source of support for older adults with chronic illness and disability. Thousands of published empirical studies and dozens of reviews have documented the psychological and physical health effects of caregiving, identified caregivers at risk for adverse outcomes, and evaluated a wide range of intervention strategies to support caregivers. Caregiving as chronic stress exposure is the conceptual driver for much of this research. We review and synthesize the literature on the impact of caregiving and intervention strategies for supporting caregivers. The impact of caregiving is highly variable, driven largely by the intensity of care provided and the suffering of the care recipient. The intervention literature is littered with many failures and some successes. Successful interventions address both the pragmatics of care and the emotional toll of caregiving. We conclude with both research and policy recommendations that address a national agenda for caregiving.

Unmet care needs in the oldest old with social loss experiences: results of a representative survey

Background

Loss experiences such as the loss of a spouse, a close relative or significant others become more likely in old age and may be strongly related to specific unmet health care needs. These unmet needs may often remain undetected and undertreated followed by a negative impact on well-being and social role functioning. The present study aims at exploring the relationship between loss experiences and specific unmet care needs in old age.

Methods

As part of the study „Need assessment in the oldest old: application, psychometric examination and establishment of the German version of the Camberwell Assessment of Need for the Elderly (CANE)”, the adapted German version of the CANE was used in a population-representative telephone survey in a sample of 988 individuals aged 75+ years. Loss experiences within the last 12 months were assessed within the structured telephone survey. Descriptive and interferential statistical analyses were run in order to examine the association between loss experiences and occurring unmet care needs.

Results

Overall, 29.7% of the oldest old reported at least one social loss with other relatives losses being the most frequent (12.5%), followed by non-family losses (10.7%). A significant relationship between loss experiences and a higher number of unmet care needs was observed, especially for close family losses. Other risk factors for unmet care needs were age, marital status, depression, social support and morbidity.

Conclusions

This study provides, for the first time in Germany, data on the association between loss experiences and unmet needs. These findings may substantially contribute to the development of loss-specific interventions, effective treatment and health care planning for the bereaved elderly.

Content of Home-Based Dementia Care: Adverse Consequences of Unmet Toileting Needs

Despite high-intensity caregiving support, those with dementia may experience adverse consequences because the care they receive does not match their care needs. This study evaluates the relationship between content of care (i.e., specific assistance with toileting) and adverse consequences (i.e., toileting accidents because no one was there to help) in a population of community-dwelling Medicare beneficiaries with dementia and impairment in toileting enrolled in the National Health and Aging Trends Study (NHATS). Only two thirds of individuals received specific assistance with toileting, which was associated with a reduced risk of adverse consequences related to toileting in a multivariable model adjusted for key variables including high-intensity caregiving (odds ratio [OR] = 0.36, 95% confidence interval [CI] = [0.23, 0.58]). To ensure care meets the needs of those with dementia living in the community, it is important to consider not only the quantity but also the content of care received.

Housing Plus Services, IADL Impairment, and Healthcare Expenditures: Evidence From the Medicare Current Beneficiaries Survey

BACKGROUND AND OBJECTIVES

Despite enthusiasm for the potential cost savings of embedding supportive services in senior housing, few population health studies have empirically examined such associations. We investigated the extent to which associations between housing plus services in senior housing and healthcare expenditures depend upon residents' instrumental activities of daily living (IADL) impairment and the level of services available.

RESEARCH DESIGN AND METHODS

We used data from 2,601 participants aged 65 or older in the 2001-2013 Medicare Current Beneficiary Survey, who reported living in senior or retirement housing. Based on survey self-reports, we created a measure of housing with different levels of services, including the categories of housing without services, housing plus services (i.e., assistance with IADLs, but not with medications), and housing plus enhanced services (i.e., assistance with IADLs including medications). Administrative and survey data were used to create measures of healthcare expenditures paid by all sources. We estimated generalized linear models based on pooled data from participants across the 13 years of data collection.

RESULTS

Residents with IADL impairment-who lived in housing plus enhanced services-had lower total healthcare expenditures than their counterparts in housing without services and housing plus services. Upon examining component healthcare costs, this pattern of results was similar for inpatient/subacute care, as well as ambulatory care, but not for home health care.

DISCUSSION AND IMPLICATIONS

Findings indicate the importance of studies on the cost savings of housing-based service programs to consider resident IADL status and the types of services available.

Indicators of potential health-related social needs and the association with perceived health and well-being outcomes among community-dwelling medicare beneficiaries

PURPOSE

Health-related social needs (HRSNs) can make older adults' more vulnerable and impact their health, well-being, and ability to age-in-place. The current study assessed the prevalence of potential HRSNs (pHRSNs) across several domains (e.g., transportation, social isolation) and explored the associations with health and well-being outcomes in a sample of Medicare beneficiaries.

METHODS

Cross-sectional analyses were conducted with a representative sample of community-dwelling Medicare beneficiaries (N = 5758) from the 2012 National Health and Aging Trends Study. Binary indicators of pHRSNs were created for five domains: medical and utility financial needs (MUFN), housing, nutrition, social isolation, and transportation. Outcomes were depression/anxiety, self-rated health, meaning/satisfaction, perceived control/adaptability. Variables were weighted, and multivariate regression models assessed associations between pHRSN variables and outcomes, controlling for sociodemographics and health conditions.

RESULTS

Of the estimated 32 million community-dwelling beneficiaries, approximately 13.3 million were positive for ≥ 1 pHRSN and 11.4 million for ≥ 2 pHRSNs. The prevalence by domain was 7% for housing, 8% for transportation, 12% for UMFN and nutrition, and 33% for social isolation. Each domain, except for housing, was significantly (p < .05) associated with at least two of the four outcomes, where being positive for a pHRSN was associated with greater depression/anxiety and poorer self-rated general health.

CONCLUSIONS

Over 40% of Medicare beneficiaries had ≥ 1 pHRSN indicators, which means they are more vulnerable and that may limit their ability to age-in-place. Given the growing aging population, better measures and methods are needed to identify, monitor, and address HRSNs. For example, leveraging existing community-based services through coordinated care may be an effective strategy to address older adults' HRSNs.

Living in the Community With Dementia: Who Receives Paid Care?

OBJECTIVES

Paid caregivers (eg, home health aides and personal care attendants) provide hands-on care that helps individuals with dementia live in the community. This study (a) characterizes paid caregiving among community-dwelling individuals with dementia and (b) identifies factors associated with receipt of paid care.

DESIGN

Cross-sectional analysis.

SETTING

The 2015 National Health and Aging Trends Study (NHATS), a nationally representative study of Medicare recipients aged 65 years and older.

PARTICIPANTS

Community-dwelling individuals with dementia (n = 899).

MEASUREMENTS

Paid and family caregiving support was determined by participant or proxy report of help received with functional tasks. Multivariable logistic regression was used to examine factors associated with receipt of paid care. NHATS population sampling weights were used to produce national paid caregiving prevalence estimates.

RESULTS

Only 25.5% of community-dwelling individuals with dementia received paid care, and 10.8% received 20 hours or more of paid care per week. For those who received it, paid care accounted for approximately half of the 83 total caregiving hours (paid and family) that they received each week. Among the subgroup of individuals with advanced dementia (those with impairment in dressing, bathing, toileting, and managing medications and finances), nearly half (48.3%) received paid care. Multivariable analysis, adjusting for sociodemographic, family caregiving support, functional, and clinical characteristics, found that the odds of receiving paid care were higher among men (odds ratio [OR] = 1.91; 95% confidence interval [CI] = 1.24-2.95), the unmarried (OR = 2.20; 95% CI = 1.31-3.70), those with Medicaid (OR = 2.16; 95% CI = 1.27-3.66), and those requiring more help with activities of daily living (ADLs) (OR = 1.32; 95% CI = 1.18-1.48) and instrumental ADLs (OR = 1.29; 95% CI = 1.14-1.46).

CONCLUSIONS

New ways of making paid caregiving more accessible throughout the income spectrum are required to support family caregivers and respect the preferences of individuals with dementia to remain living in the community. J Am Geriatr Soc 68:186-191, 2019.

Unmet needs in community-living persons with dementia are common, often non-medical and related to patient and caregiver characteristics

OBJECTIVE

Understanding which characteristics of persons with dementia (PWD) and their caregivers are associated with unmet needs can inform strategies to address those needs. Our purpose was to determine the percentage of PWD having unmet needs and significant correlates of unmet needs in PWD.

DESIGN

Cross-sectional data were analyzed using bivariate and hierarchical multiple linear regression analyses.

SETTING

Participants lived in the greater Baltimore, Maryland and Washington DC suburban area.

PARTICIPANTS

A sample of 646 community-living PWD and their informal caregivers participated in an in-home assessment of dementia-related needs.

MEASUREMENTS

Unmet needs were identified using the Johns Hopkins Dementia Care Needs Assessment. Correlates of unmet needs were determined using demographic, socioeconomic, clinical, functional and quality of life characteristics of the PWD and their caregivers.

RESULTS

PWD had a mean of 10.6 (±4.8) unmet needs out of 43 items (24.8%). Unmet needs were most common in Home/Personal Safety (97.4%), General Health Care (83.1%), and Daily Activities (73.2%) domains. Higher unmet needs were significantly related to non-white race, lower education, higher cognitive function, more neuropsychiatric symptoms, lower quality of life in PWD, and having caregivers with lower education or who spent fewer hours/week with the PWD.

CONCLUSIONS

Unmet needs are common in community-living PWD, and most are non-medical. Home-based dementia care can identify and address PWD's unmet needs by focusing on care recipients and caregivers to enable PWD to remain safely at home.

Evaluation of Tailored Falls Education on Older Adults' Behavior Following Hospitalization

BACKGROUND

Older adults recently discharged from the hospital are known to be at risk of functional decline and falls. This study evaluated the effect of a tailored education program provided in the hospital on older adult engagement in fall prevention strategies within 6 months after hospital discharge.

METHODS

A process evaluation of a randomized controlled trial that aimed to improve older adult fall prevention behaviors after hospital discharge. Participants (n = 390) were aged 60 years and older with good cognitive function (greater than 7 of 10 Abbreviated Mental Test Score), discharged home from three hospital rehabilitation wards in Perth, Australia. The primary outcomes were engagement in fall prevention strategies, including assistance with daily activities, home modifications, and exercise. Data were analyzed using generalized linear modeling.

RESULTS

There were 76.4% (n = 292) of participants who completed the final interview (n = 149 intervention, n = 143 control). There were no significant differences between groups in engagement in fall prevention strategies, including receiving instrumental activity of daily living (IADL) assistance (adjusted odds ratio [AOR] = 1.3 [95% confidence interval {CI} = 0.7-2.1]; P = .3), completion of home modifications (AOR = 1.2 [95% CI = 0.7-1.9]; P = .4), and exercise (AOR = 1.3 [95% CI = 0.7-2.2]; P = .3). There was a high proportion of unmet ADL needs within both groups, and levels of participant dependency remained higher at 6 months compared to baseline levels at admission. The proportion of all participants who engaged in exercise following hospital discharge increased by 30%; however, the mean duration of exercise reduced from 3 hours per week at baseline to 1 hour per week at 6-month follow-up (SD = 1.12 hours per week).

CONCLUSION

Tailored education did not increase older adult engagement in fall prevention strategies after hospital discharge compared to usual care. Further research is required to evaluate older adults' capacity to change their behaviors once they return home from hospital, which may enable a safer recovery of their independence. J Am Geriatr Soc 67:2274-2281, 2019.

Care Recipient Concerns About Being a Burden and Unmet Needs for Care

Background

Disabled older adults' needs for help with daily activities sometimes go unmet with potentially long-term negative consequences for health and well-being.

Objectives

To examine the relationship between care recipient unmet needs and (1) concerns about being a burden; (2) perceptions of caregiver burden; and (3) and caregiver self-reports of burden in community-dwelling care recipient-caregiver dyads.

Research Design and Methods

Telephone surveys with 196 linked caregiver-care recipient dyads from the 2017 Pittsburgh Regional Caregiver Survey. Of 376 caregivers who gave initial permission to contact the recipient (February-July), 262 caregivers were recontacted and gave permission to attempt a care recipient survey (September-October; n = 196 completed; 74.8% response rate). In addition to the burden measures, we controlled for several covariates, including disability level, receipt of paid help, and care recipient and caregiver sociodemographics.

Results

Slightly more than one fourth (27.2%) of care recipients were "very concerned" about being a burden, and 43.6% were "somewhat concerned." Care recipient concerns about being a burden (exp(B) = 1.71, 95% confidence interval [CI] exp(B) [1.15, 2.54]); and caregiver self-reported burden (exp(B) = 1.82, 95% CI exp(B) [1.17, 2.85]) were independent predictors of more care recipient unmet needs. Recipient perceptions of caregiver burden were not independently predictive. Care recipients with higher disability levels, those without paid help, and those whose caregiver was not a spouse/child also reported more unmet needs. The impact of burden on unmet needs was stronger for instrumental activities of daily living/mobility needs than for activities of daily living needs.

Discussion and Implications

Potential interventions to reduce unmet needs should take a dyadic approach, focusing on reducing both care recipient perceptions of being a burden and caregiver experienced burden.

Adaptations of the evidence-based Transitional Care Model in the U.S

Despite a growing body of evidence that adaptations of evidence-based interventions (EBI) are ubiquitous, few studies have examined the nature and rationale for modifications to the components of these interventions. The primary aim of this study was to describe and classify common local adaptations of the Transitional Care Model (TCM), an EBI comprised of 10 components that has been proven in multiple clinical trials to improve the care and outcomes of chronically ill older adults transitioning from hospitals to home. Guided by Stirman's System of Classifying Adaptations, 582 transitional care clinicians in health systems and community-based organizations throughout the U.S. completed a survey between September 2014 and January 2015; interviews were then conducted with a subset of survey respondents (N = 24) between April and December 2015. A total of 342 survey respondents (59%) reported implementation of the TCM in distinct organizations. Of this group, 96% reported a mean of 4.4 adaptations to the 10 TCM components (40%, one to three; 43%, four to six; and 17%, seven to nine). Nine of ten respondents (94%) reported contextual adaptations while content adaptations were less frequently reported (58%). The top three reported adaptations all related to context (i.e., delivering services from hospital to home, relying on advance practice nurses, and fostering care continuity); interviews clarified a diverse set of reasons for such modifications. Findings reinforce the need for investment in adaptation science and suggest hypotheses to guide rigorous examination of the association between adaptations of TCM components and desired outcomes.