The Home Care Workforce Has Not Kept Pace With Growth In Home And Community-Based Services

The dementia care workforce: Essential to care but large research gaps exist

People living with dementia and their care partners benefit from services and supports from a wide variety of healthcare and social service professionals. This article provides an overview of the dementia care workforce and highlights gaps and opportunities for data collection and research to advance the workforce and its contributions to high-quality care. The authors provide an analysis of literature, trends, research gaps, and research opportunities, drawing from the literature and their own research. There are notable gaps in our ability to track career pathways, assess the impact of training, identify best practices for recruitment and retention, and understand attributes of the workforce that may affect the quality of both workers' lives and the care they provide to people living with dementia. There are many opportunities for new research to help direct care workers meaningfully contribute to the health and well-being of people living with dementia and their care partners. HIGHLIGHTS: The dementia care workforce works in multiple settings and includes many occupations. There are gaps in knowledge regarding the workforce and its role in high-quality care. Evaluation research is needed to improve direct care worker recruitment, retention, and knowledge. Research on caregiving teams including direct care workers, other workers, and families is needed.

Behavioral, Cognitive, and Functional Risk Factors for Repeat Hospital Episodes Among Medicare-Medicaid Dually Eligible Adults Receiving Long-Term Services and Supports

Repeat hospitalizations adversely impact the well-being of adults dually eligible for Medicare and Medicaid in the United States. This study aimed to identify behavioral, cognitive, and functional characteristics associated with the risk of a repeat hospital episode (HE) among the statewide population of dually eligible adults in Maryland receiving long-term services and supports prior to an HE between July 2018 and May 2020. The odds of experiencing a repeat HE within 30 days after an initial HE were positively associated with reporting difficulty with hearing (adjusted odds ratio, AOR: 1.10 [95% confidence interval: 1.02-1.19]), being easily distractible (AOR: 1.09 [1.00-1.18]), being self-injurious (AOR: 1.33 [1.09-1.63]), and exhibiting verbal abuse (AOR: 1.15 [1.02-1.30]). Conversely, displaying inappropriate public behavior (AOR: 0.62 [0.42-0.92]) and being dependent for eating (AOR: 0.91 [0.83-0.99]) or bathing (AOR: 0.79 [0.67-0.92]) were associated with reduced odds of a repeat HE. We also observed differences in the magnitude and direction of these associations among adults 65 years of age or older relative to younger counterparts.

Consumer-Directed Personal Care in the New York Metropolitan Area: Trends in Use From 2017 to 2022

OBJECTIVES

Despite growing interest in expansion of consumer- (or self-) directed models of Medicaid-funded personal care, research characterizing program use is limited. We leverage health plan and claims data from a large health plan in New York to examine (1) trends in use of consumer-directed care and (2) the impact of the COVID-19 pandemic on consumer-directed care use.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All individuals enrolled in a large, New York health plan who received Medicaid-funded personal care between January 2017 and December 2022 (n = 47,216).

METHODS

Proportion of enrollees receiving consumer-directed care during each month and year was calculated for all enrollees and the subgroups of new and existing enrollees. An interrupted time series model was estimated to examine time trends and impact of the COVID-19 pandemic onset on trends.

RESULTS

Between 2017 and 2022, the proportion of enrollees receiving consumer-directed care increased from 10.3% to 47.9%. Sociodemographic characteristics and average personal care hours remained stable. Models identified a 6% yearly increase in the proportion of enrollees using consumer-directed care pre-pandemic, (P < .001) an immediate 4% bump in use in March 2020 at the onset of the COVID-19 pandemic (P = .001), and an 8% yearly increase in use post pandemic onset (P = .01). Although trends among existing enrollees mirrored overall trends, new enrollees had larger increases in consumer-directed care use early in the study period, which leveled off after March 2020.

CONCLUSIONS AND IMPLICATIONS

While there was a statistically significant and sustained increase in the proportion of enrollees receiving consumer-directed care at onset of the COVID-19 pandemic, the magnitude of this increase was small in comparison with overall program growth between 2017 and 2022. Additional work to understand how other factors contribute to enrollees choosing consumer-directed care is needed to ensure all Medicaid-funded personal care recipients can have their needs met in the community.

Increasing expenditures on home- and community-based services: Do home care workers benefit?

OBJECTIVE

To examine the association of Medicaid home- and community-based services (HCBS) expenditures on the home care workforce.

DATA SOURCES/STUDY SETTING

We use two national, secondary data sources from 2008 to 2019: state-level Medicaid HCBS expenditures and the American Community Survey, in which we identify direct care workers in the home (i.e., home care workers), defined as nursing, psychiatric, and home health aides or personal care aides working in home health care services, individual and family services, and private households.

STUDY DESIGN

Our key explanatory variable is HCBS expenditures per state per year. To estimate the association between changes in Medicaid HCBS expenditures and the workforce size, hourly wages and hours worked, we use negative binomial, linear, and generalized ordered logit regression, respectively. All models include demographic and socioeconomic characteristics, the number of potential HCBS beneficiaries (individuals with a disability and income under the federal maximum income eligibility limits), indicators for minimum wage and/or overtime protections for direct care workers, wage pass-through policies, and state and year fixed effects.

DATA COLLECTION/EXTRACTION METHODS

We exclude states with incomplete reporting of expenditures.

PRINCIPAL FINDINGS

States' HCBS expenditures increased between 2008 and 2019 after adjusting for inflation and the number of potential HCBS beneficiaries. Yet, home care workers' wages remained stagnant at $11-12/h. We find no association between changes in Medicaid HCBS expenditures and wages. For every additional $1 million in Medicaid HCBS expenditures, the expected number of workers increases by 1.2 and the probability of working overtime increased (0.0015% points; p < 0.05). Results are largely robust under multiple sensitivity analyses.

CONCLUSIONS

We find no evidence of a statistically significant relationship between changes in state-level changes in Medicaid HCBS expenditures and worker wages but do find a significant, but small, association with hours worked and workforce size.

Rationing Rights: Administrative Burden in Medicaid Long-Term Care Programs

CONTEXT

States use Medicaid waivers to provide supports for disabled people in communities rather than in institutions. Because waivers are not entitlements, those deemed eligible are not guaranteed these supports. How do states, in practice, use bureaucratic procedures to ration this "conditional" right?

METHODS

Drawing on primary and secondary data, the authors analyze waiver programs and document state administrative procedures that indirectly and directly ration access.

FINDINGS

Burdens indirectly limit disabled people's access to Medicaid home- and community-based services via a complex array of waiver programs that exacerbate costs associated with gaining eligibility. In addition, burdens directly limit access via wait lists and prioritization among the eligible. There is also evidence that states strategically deploy opaqueness to provide political cover for unpopular wait lists. The overall process is opaque, confusing, and time intensive, with burdens falling hardest on marginalized groups.

CONCLUSIONS

Administrative burdens impede disabled people's efforts to exercise their right to live in the community as afforded to them under the American with Disabilities Act. The opaqueness and associated burdens with waiver programs are a way to conceal these burdens, thereby demonstrating how burdens "neatly carry out the 'how' in the production of inequality, while concealing . . . the why" (Ray, Herd, and Moynihan 2023: 139).

"Too few, too far away, for what is paid": Consumer voices about the personal assistance worker crisis

BACKGROUND

The growing gap between demand and supply of personal assistance service (PAS) workers presents a significant burden to those who use services. The intensity and duration of hardship is growing, and consumer voices need to be heard and incorporated into the national dialogue.

OBJECTIVE

This paper explores how PAS worker shortages manifest themselves in the daily lives of people with disabilities using or needing PAS services in the United States.

METHODS

We used thematic coding of qualitative data from the 2022 National Survey on Health and Disability. Respondents (n = 330) provided open-ended responses to the prompt "Briefly explain the types of problems or issues you have had finding PAS or support workers."

RESULTS

Three themes emerged regarding consumer perspectives and experiences with worker shortages (1) low pay, few benefits, and undervalued work, (2) demanding working conditions and logistics, and (3) low quality workers. In combination, these themes informed a fourth theme (4) impacts for PAS consumers characterized by substandard care and additional stress and workload for those who direct their own care.

CONCLUSIONS

As a society, we have taken steps to increase opportunities for community living and created policies to uphold choice and independence for people with disabilities. In the absence of an adequate workforce to support these policies, however, we convey an empty promise. Without tangible steps to resolve these problems at the policy level, such as improved worker pay and protections, hope for resolution to these issues remains elusive.

Supporting the home care workforce across the Southern United States: impetus, exploration, and policy strategies

Southern states face severe home care labor shortages due to low wages, poor working conditions, and limited career advancement opportunities, which are exacerbated by the region's historical labor policies and economic inequalities. This study analyzed workforce size in relation to the population of older adults likely to require paid home care services, subsequently contextualizing those results using a thematic analysis of state American Rescue Plan Act section 9817 spending plans to identify trends in proposed initiatives designed to strengthen the workforce across the region. Our findings highlight significant disparities in workforce availability, with more diverse areas with higher concentrations of Hispanic, immigrant, and low-income populations exhibiting higher workforce capacity compared with less diverse regions. We also found consensus across states on the inadequacy of direct care worker wages, demonstrated by the large number of proposed reimbursement rate increases included in the state spending plans.

What Do Unions Do for Direct Care Workers? Assessing Employment and Economic Outcomes

OBJECTIVES

Our study investigates unionization trends among direct care workers (DCWs) in the United States and examines the association between unionization and their wealth outcomes.

DESIGN

This is a cross-sectional study using data from the Current Population Survey and Annual Social and Economic Supplement from 2009 to 2023.

SETTING AND PARTICIPANTS

Our study is based on US representative household surveys. The sample includes 17,522 DCWs (eg, personal care aides, nursing assistants, home health workers).

METHODS

The prevalence and trend in labor unionization among DCWs and the association between their union status and wealth outcomes (hourly wage, employer-sponsored health insurance, pension plans, and poverty status) were analyzed. Union status identified by formal union membership or coverage by a union without formal membership.

RESULTS

The sample was composed of mostly women (87%); they had a mean age of 41.8 ± 14.5 years, 38.1% were non-Hispanic White, 30.4% were non-Hispanic Black, 21.6% were Hispanic, and 9.9% were Asian and other. Overall, 12% (n = 1850) of DCWs were unionized. The Cox trend test showed decreasing in unionization rates over the study years. In fully adjusted models, unionized DCWs earned more than nonunionized DCWs ($1.2; 95% CI, $0.8-$1.6; P < .001). They were also more likely to have employer-sponsored health care insurance (odds ratio, 2.0; 95% CI, 1.8-2.3; P < .001) and pension plan (odds ratio, 1.8; 95% CI, 1.6-2.0; P < .001), with higher employer's contribution to health insurance ($561.2; 95% CI, $303.1-$819.3; P < .001). Also, unionization was negatively associated with DCWs' poverty status (odds ratio, 0.7; 95% CI, 0.6-0.9; P < .001).

CONCLUSIONS AND IMPLICATIONS

Unionization is an effective means of improving the financial well-being of DCWs, a workforce that is currently facing challenging working conditions and high levels of turnover.

Care shortages and duties to age abroad

Many higher-income countries have shortages of care-workers, which is unlikely to change in the foreseeable future as virtually all of these societies are ageing. The philosophical literature on this problem has concentrated mostly on the merits and demerits of different policy solutions, especially on the recruitment of foreign care-workers and on investments in care robots and other relevant technologies. However, the question of what moral duties, if any, private individuals have to help address care-worker shortages has been entirely neglected. In this article, I help to fill this lacuna by arguing that some inhabitants of higher-income countries have moral duties to age abroad in order to reduce the pressure on the aged care-systems of their current societies, whereby 'ageing abroad' is defined narrowly as moving to a foreign country to receive residential or non-residential aged care. As I show, these duties are dependent on a number of conditions being met, including the requirement that the host populations not be made worse off.

"They seemed to forget about us little people": the lived experiences of personal care attendants during the COVID-19 pandemic

Background

Personal care attendants (PCAs) provided essential care and support to home care clients during the COVID-19 pandemic and thus were a vital part of the pandemic response in helping to keep older adults and individuals with disabilities out of nursing homes. Furthermore, they are one of the largest and fastest growing workforces in the United States. Yet this essential workforce received little attention during the pandemic. Guided by feminist theories on caregiving and the principles of community-based participatory research, this study examined the experiences of PCAs during the COVID-19 pandemic.

Methods

Data from 78 in-depth interview participants representing Medicaid-Funded Home and Community-Based Services (HCBS) PCAs, clients, family caregivers, and service providers in Kansas, United States, as well as additional data from 176 PCA survey participants were analyzed. Findings from this interactive, convergent, mixed-methods study were integrated by theme using the weaving approach.

Results

Four major themes emerged from the analysis: (1) PCAs remained in this field during the pandemic out of a commitment to their clients; (2) PCAs were undervalued and invisible as an essential workforce; (3) direct care work had an emotional toll on PCAs during the pandemic; and (4) PCAs have mixed feelings about their satisfaction with the job, and, as good workers quit, they were difficult to replace.

Discussion

PCAs held professional-level responsibilities without the recognition or pay of a professional. The pandemic had mixed impacts on job stress and satisfaction, suggesting that the intrinsic rewards of the job and social support had a protective impact. However, intrinsic rewards are not enough to retain this workforce, and the growing PCA workforce shortage leaves many clients having to choose between no care and poor care. Our findings indicate that institutions and systems must better support and recognize this essential workforce to build and maintain a quality in-home care services system.

Home health utilization in the Veterans Health Administration: Are there rural and urban differences?

PURPOSE

Growing numbers of older adults need home health care, yhese services may be more difficult to access for rural Veterans, who represent one-third of Veterans Health Administration (VA) enrollees. Our objective was to examine whether home health use differs within VA based on rurality.

METHODS

We examined national VA administrative data for 2019-2021 (January 1, 2019 to December 31, 2021) among Veterans ages ≥65 years. Using descriptive and multivariable analyses, we assessed whether rural versus urban Veterans differed in (1) the likelihood of using any home health and (2) for those who received ≥1 visit, number of visits received.

RESULTS

Among home health users (n = 107,229, 33.1% rural), rural and urban Veterans were similar in age (77.0 vs. 77.2 years). Rural Veterans were less likely to be highly frail (38.9% rural vs. 40.4% urban) or diagnosed with dementia (13.5% vs. 17.6%). After adjusting for Veterans' characteristics, rural Veterans were more likely to receive any home health (odds ratio: 1.10; 95% confidence interval [CI]: 1.07, 1.13). Among Veterans who received ≥1 home health visit, rurality was associated with considerably fewer expected visits (incident rate ratio: 0.70; 95% CI: 0.68, 0.72).

CONCLUSIONS

Although rural Veterans were more likely than urban Veterans to receive any home health services, they received considerably fewer home health visits. This difference may represent an access issue for rural Veterans. Future research is needed to identify reasons for these differences and develop strategies to ensure rural Veterans' care needs are equitability addressed.

The Impact of an Intergenerational Service Learning Program on Psychological Distress for Homebound Older Adults

This study examined the benefits of an intergenerational home-based service learning program to reduce psychological distress for homebound older adults. Multivariate regression analyses were conducted with a sample of 182 to examine the association of length of service from the program and presence of caregivers with psychological distress. Findings indicated length of service (β = -0.15, p < .05) and having a child as a caregiver (β = -0.14, p < .05) were associated with a reduction in psychological distress. Policies and practice can support a pipeline of geriatric health professionals through innovative service learning models to benefit older adults, caregivers, and students.

Overcoming challenges to optimize the clinical and financial benefits of in-home rehabilitation services

The authors advocate for the implementation of value-based principles to address the underutilization and limited supply of home care and rehabilitation services.

Association Between Self-Direction and Personal Care Aide Wages

The supply of personal care aides (PCAs), who assist people receiving home care, is a growing concern. PCA shortages result, in part, from the low wages earned by these workers. State policies have had some effect on wages. Self-direction (SD) may be associated with wages because SD allows home care recipients to hire and manage workers, including setting wages in most states. We used wage data from the Bureau of Labor Statistics to examine the association between SD and the wages of PCAs. We found implementation of SD did not have a consistent association with PCA wages, with wages improving in some states and worsening in others. We also found little difference in PCA wages between states that allow participants to set worker wages and those that do not. SD does not seem to improve PCA wages in states, so other policy strategies will be needed.

Family caregiver lived experience matters in home- and community-based services

This editorial comments on the article by Trivedi et al.

Home Care Workers Providing Person-Centered Care to People With Dementia

Person-centered care for people living with dementia has been associated with improved functional ability and quality of life, yet little is known about person-centered care in the home settings. Our objective was to explore home care worker perspectives on providing person-centered care for their clients living with dementia. Using secondary qualitative analysis of 22 semi-structured interviews with home care workers, we identified themes related to the Dementia Initiative's person-centered dementia care framework (Initiative, 2013). We found that home care workers acknowledged their client's personhood while also advocating for their needs. However, home care workers encountered barriers to providing person-centered care, including role limitations and challenging dynamics with other home care workers and family caregivers. This analysis can inform further approaches to better integrate home care workers in person-centered healthcare teams and improve how the needs of people living with dementia are identified and met in the home.

VHA Support for Home Health Agency Staff and Patients During Natural Disasters

Background

Home health agencies (HHAs) provide vital community-based services for older adults. Under-resourced HHAs that are disconnected from broader community emergency planning efforts may struggle to maintain services during emergencies. As climate-related disasters become more prevalent, HHA services are increasingly at risk, and policymakers have focused on the services they provide to older adults. This study explores the relationships between the Veterans Health Administration (VHA) and contracted HHAs to identify opportunities to extend VHA emergency resources to HHAs and staff to assist them during disasters.

Methods

We interviewed 19 stakeholders from 6 Veterans Affairs medical centers. Data were analyzed through rapid qualitative analysis.

Results

VHA and HHA staff focused primarily on their disaster response during emergencies with little knowledge of each other's protocols. VHA emergency managers lacked direct relationships with staff overseeing HHAs but had strong internal partnerships with clinicians and were knowledgeable about the needs of veterans who were disabled and homebound. VHA staff demonstrated an interest in partnering with HHAs to identify resources that could be shared during emergencies.

Conclusions

Creating a pipeline of support through existing relationships and resources has the potential to strengthen VHA protections for older adults during emergencies, help them age safely in place, and provide a model for other health systems to collaborate with community-based practitioners.

Tracking long-term services and supports rebalancing through workforce data

OBJECTIVE

To understand trends in the long-term services and supports (LTSS) workforce and assess workforce data as a measure of progress in shifting LTSS resources from institutional to community-based settings.

DATA SOURCES/STUDY SETTING

Workforce data from the American Community Survey from 2008 to 2022.

STUDY DESIGN

Measures of LTSS rebalancing and institutional and community workforce supply per 1000 persons with LTSS needs were constructed. After showing national trends over the study period, state fixed effects regressions were used to evaluate the within-state relationship of these measures with existing measures of LTSS utilization. Workforce supply measures were compared to the percentage of state Medicaid LTSS spending spent in the community to assess their utility for across state comparisons. Each state's progress in LTSS rebalancing over the study period was then shown using workforce data.

DATA COLLECTION/EXTRACTION METHODS

A sample of 336,316 LTSS workers and 3,015,284 people with LTSS needs over the study period was derived from American Community Survey data.

PRINCIPAL FINDINGS

From 2008 to 2022, the percentage of the LTSS workforce employed in the community rose from 44% to 58%. Thirty states saw more than a 10 percentage point increase. From 2008 to 2013, the size of the community workforce expanded dramatically but has since stagnated. In contrast, the institutional workforce entered a long-term decline beginning in 2015 that accelerated during the COVID-19 pandemic. State fixed effects regressions showed that measures of workforce supply have a strong relationship with LTSS utilization measures for older adults, but not for younger people with disabilities.

CONCLUSIONS

Workforce data can serve as an effective measure of changes in LTSS utilization for older adults. This offers researchers and policymakers a useful alternative to administrative claims, bypassing threats to comparability from coding changes and the shift to managed care. Additional data is needed on workforce trends in services for younger LTSS consumers.

Paid Caregiving in Dementia Care Over Time: Paid Caregiver, Family Caregiver, and Geriatrician Perspectives

BACKGROUND AND OBJECTIVES

As long-term care increasingly moves from facilities to the community, paid caregivers (e.g., home health aides, other home care workers) will play an increasingly important role in the care of people with dementia. This study explores the paid caregiver role in home-based dementia care and how that role changes over time.

RESEARCH DESIGN AND METHODS

We conducted individual, longitudinal interviews with the paid caregiver, family caregiver, and geriatrician of 9 people with moderate-to-severe dementia in the community; the 29 total participants were interviewed on average 3 times over 6 months, for a total of 75 interviews. Interviews were recorded, transcribed, and analyzed with structured case summaries and framework analysis.

RESULTS

Paid caregivers took on distinct roles in the care of each client with dementia. Despite changes in care needs over the study period, roles remained consistent. Paid caregivers, family caregivers, and geriatricians described the central role of families in driving the paid caregiver role. Paid and family caregivers collaborated in the day-to-day care of people with dementia; paid caregivers described their emotional relationships with those they cared for.

DISCUSSION AND IMPLICATIONS

Rather than simply providing functional support, paid caregivers provide nuanced care tailored to the needs and preferences of not only each person with dementia (i.e., person-centered care), but also their family caregivers (i.e., family-centered care). Deliberate cultivation of person-centered and family-centered home care may help maximize the positive impact of paid caregivers on people with dementia and their families.

Proactive Care-Seeking Strategies Among Adults Aging Solo With Early Dementia: A Qualitative Study

OBJECTIVES

People living with dementia need increasing care over time, but 1 in 3 adults with cognitive impairment lives alone. The goal of this study was to explore the self-identified strengths and resources for future care needs of adults aging solo with early dementia.

METHODS

Semistructured interviews with 15 adults not living with a partner and with no children in the same state, who self-identified as having early dementia or mild cognitive impairment; hybrid inductive/deductive reflexive thematic analysis using a successful aging framework.

RESULTS

Participants placed a high value on maintaining independence and expressed concerns about preserving selfhood and becoming a burden to others. These values influenced how participants appraised financial and social resources available to address future care needs and strategies to preempt or respond to needs such as transportation, help with finances, or activities of daily living.

DISCUSSION

Adults without close family are heterogeneous and have variable resources available to address care needs associated with dementia progression. Common values of retaining independence and minimizing burden to others may be helpful in motivating adults aging solo to undertake planning and help-seeking early.

Assessing the Usability and Feasibility of Digital Assistant Tools for Direct Support Professionals: Participatory Design and Pilot-Testing

BACKGROUND

The United States is experiencing a direct support professional (DSP) crisis, with demand far exceeding supply. Although generating documentation is a critical responsibility, it is one of the most wearisome aspects of DSPs' jobs. Technology that enables DSPs to log informal time-stamped notes throughout their shift could help reduce the burden of end-of-shift documentation and increase job satisfaction, which in turn could improve the quality of life of the individuals with intellectual and developmental disabilities (IDDs) whom DSPs support. However, DSPs, with varied ages, levels of education, and comfort using technology, are not likely to adopt tools that detract from caregiving responsibilities or increase workload; therefore, technological tools for them must be relatively simple, extremely intuitive, and provide highly valued capabilities.

OBJECTIVE

This paper describes the development and pilot-testing of a digital assistant tool (DAT) that enables DSPs to create informal notes throughout their shifts and use these notes to facilitate end-of-shift documentation. The purpose of the pilot study was to assess the usability and feasibility of the DAT.

METHODS

The research team applied an established user-centered participatory design process to design, develop, and test the DAT prototypes between May 2020 and April 2023. Pilot-testing entailed having 14 DSPs who support adults with IDDs use the first full implementation of the DAT prototypes during 2 or 3 successive work shifts and fill out demographic and usability questionnaires.

RESULTS

Participants used the DAT prototypes to create notes and help generate end-of-shift reports. The System Usability Scale score of 81.79 indicates that they found the prototypes easy to use. Survey responses imply that using the DAT made it easier for participants to produce required documentation and suggest that they would adopt the DAT if this tool were available for daily use.

CONCLUSIONS

Simple technologies such as the DAT prototypes, which enable DSPs to use mobile devices to log time-stamped notes throughout their shift with minimal effort and use the notes to help write reports, have the potential to both reduce the burden associated with producing documentation and enhance the quality (level of detail and accuracy) of this documentation. This could help to increase job satisfaction and reduce turnover in DSPs, both of which would help improve the quality of life of the individuals with IDDs whom they support. The pilot test results indicate that DSPs found the DAT easy to use. Next steps include (1) producing more robust versions of the DAT with additional capabilities, such as storing data locally on mobile devices when Wi-Fi is not available; and (2) eliciting input from agency directors, families, and others who use data about adults with IDDs to help care for them to ensure that data produced by DSPs are relevant and useful.

Higher levels of state funding for Home- and Community-Based Services linked to better state performances in Long-Term Services and Supports

OBJECTIVE

To examine the relationship between the level of state funding for Home- and Community-Based Services (HCBS) and state overall and dimension-specific performances in Long-Term Services and Supports (LTSS).

DATA SOURCES AND STUDY SETTING

We employed state-level secondary data from the Medicaid LTSS Annual Expenditures Reports, the American Association of Retired Persons (AARP) State Scorecards, the U.S. Census, and Federal Reserve Economic data, spanning the timeframe of 2010-2020.

STUDY DESIGN

Overall state LTSS rankings, along with dimension-specific rankings, were modeled separately against state Medicaid spending on HCBS relative to total Medicaid spending on LTSS. All models were adjusted for state covariates, secular trend, and state fixed effects.

DATA COLLECTION/EXTRACTION METHODS

The study sample included all 50 states and the District of Columbia. However, California, Delaware, Illinois, and Virginia were excluded from FY2019 due to missing data on Medicaid HCBS expenditures.

PRINCIPAL FINDINGS

Every 10 percentage-point increase in the proportion of Medicaid LTSS spending to HCBS demonstrated 2.05 points improvement (95% confidence interval [CI]: -3.88 to 0.22, p = 0.03) in rankings for state overall LTSS system performance, 2.92 points improvement (95% CI: -4.87 to 0.98, p < 0.01) in rankings for the Choice of Setting and Provider dimension, as well as 1.73 points (95% CI: -3.14 to 0.32, p = 0.02) ranking improvement in the dimension of Effective Transitions.

CONCLUSIONS

Our study suggested promising effects of increased state funding for HCBS on LTSS performance.

Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion

Importance

The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known.

Objective

To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations.

Design, Setting, and Participants

Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys.

Exposure

Time-varying state-level adoption of Medicaid expansion.

Main Outcomes and Measures

Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits.

Results

The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion.

Conclusion and Relevance

Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

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

BACKGROUND

Loneliness 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.

METHODS

We 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.

RESULT

In 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.

CONCLUSION

Our 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.