Profile of Older Dual-Enrollees Living in Areas with Managed Long-Term Services and Supports

OBJECTIVES

Nearly half of all state Medicaid agencies in the United States have implemented managed long-term services and supports (MLTSS). Data gaps have inhibited our understanding of MLTSS experiences to date. We draw on a national survey with novel data linkages to develop a profile of older dual-enrollees with significant LTSS needs by MLTSS program presence.

DESIGN

Cross-sectional observational study using the 2015 round of the National Health and Aging Trends Study (NHATS), a longitudinal study of a nationally representative sample of Medicare beneficiaries aged 65 years and older.

SETTING AND PARTICIPANTS

The sample comprised 275 participants who self-reported Medicaid enrollment and met our definition of significant LTSS need as defined by receiving help with 2 or more self-care or mobility activities (eating, bathing, toileting, dressing, bed transfer, indoor mobility).

METHODS

Bivariate analyses were used to comparatively examine differences in demographic, health, and care circumstances by MLTSS, as defined by living in a county with MLTSS program presence.

RESULTS

Among approximately 1 million (weighted sample) older dual-enrollees with significant LTSS needs, 56.2% (weighted percentage) lived in counties with MLTSS and 43.7% lived in counties with mandatory MLTSS enrollment in 2015. Those living in areas with MLTSS were much more likely to be of Hispanic or other race and ethnicity (50.5% vs 15.1%, P < .001) yet less likely to live in a rural location (8.7% vs 31.4%, P < .05) or in a residential care facility or nursing home (18.4% vs 34.7%, P < .05). The majority (78.5%) received assistance from 2 or more helpers and received more than 70 hours of care per week.

CONCLUSIONS AND IMPLICATIONS

Our findings reinforce the growing reach of MLTSS programs and importance of filling evidence gaps about who these programs are serving.

Patient Portal Use during Home Health Care at an Academic Health System

OBJECTIVES

To characterize patient portal use among older adults receiving skilled home health (HH) care.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Older adults (aged ≥65 years) who received HH care from a large, academic health system between 2017 to 2022 (n = 8409 HH episodes provided to n = 4878 unique individuals).

METHODS

We captured individual and HH episode characteristics from the electronic health record and identified specific types and dates of portal use for those with an active patient portal. We calculated the proportion of episodes in which patients engaged in specific patient portal activities (eg, viewing test results, managing appointments, sending messages). We used multivariable logistic regression to model the odds of engaging in each activity as a function of patient and episode characteristics, and charted the timing of patient portal activities across the 60-day HH episode.

RESULTS

The patient portal was used by older adults in more than half (58%) of the episodes examined. Among those using their portal account during an HH episode, 84% viewed test results, 77% managed an existing appointment, 72% managed medications, and 55% sent a message to a provider. Adjusted odds of portal use were higher among HH patients who were married (aOR: 1.77, P < .001), receiving HH post-COVID pandemic (aOR: 2.73, P < .001), and accessing HH following a hospitalization (aOR: 1.30, P < .001) and lower among those who were Black compared with white (aOR: 0.52, P < .001). Portal use, particularly viewing test results and clinical notes and managing existing appointments, was highest during the first 10 days of an HH episode, especially among patients referred following a hospitalization.

CONCLUSIONS AND IMPLICATIONS

HH patients use the patient portal to perform care management tasks and access clinical information. Study findings support opportunities to harness the patient portal to bridge information gaps and care coordination during HH care.

"Caregiving is teamwork…" Information sharing in home care for older adults with disabilities living in the community

AIM

We examined information sharing between direct care workers, family caregivers, and clinicians involved in the care of older adults with disabilities.

METHODS

Semi-structured interviews with N = 11 representatives of home care agencies ("residential service agencies" in Maryland).

RESULTS

Work system and process characteristics relevant to information sharing included: (1) using electronic management systems and patient portals to communicate within agencies and with clinicians, (2) implementing tools to gather information about client goals, preferences, and routines, and (3) relying on family members for information about clients' needs. Participants did not report differences in dementia-related care coordination; however, dementia-related adaptations involved additional considerations for navigating relationships with family and standardizing processes to communicate with clinicians.

CONCLUSION

Findings highlight care demands experienced by direct care workers and support calls to better coordinate information sharing between interdisciplinary care teams.

Career development in pragmatic clinical trials to improve care for people living with dementia

The growing number of people living with dementia (PLWD) requires a coordinated clinical response to deliver pragmatic, evidence-based interventions in frontline care settings. However, infrastructure to support such a response is lacking. Moreover, there are too few researchers conducting rigorous embedded pragmatic clinical trials (ePCTs) to make the vision of high quality, widely accessible dementia care a reality. National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease and Related Dementias Clinical Trials (IMPACT) Collaboratory seeks to improve the pipeline of early career researchers qualified to lead ePCTs by funding career development awards. Even with support from the Collaboratory, awardees face practical and methodological challenges to success, recently exacerbated by the COVID-19 pandemic. We first describe the training opportunities and support network for the IMPACT CDA recipients. This report then describes the unique career development challenges faced by early-career researchers involved in ePCTs for dementia care. Topics addressed include challenges in establishing a laboratory, academic promotion, mentoring and professional development, and work-life balance. Concrete suggestions to address these challenges are offered for early-career investigators, their mentors, and their supporting institutions. While some of these challenges are faced by researchers in other fields, this report seeks to provide a roadmap for expanding the work of the IMPACT Collaboratory and initiating future efforts to recruit, train, and retain talented early-career researchers involved in ePCTs for dementia care.

Characterizing caregiving supportive services use by caregiving relationship status

BACKGROUND

Informal caregivers of older adults experience a high degree of psychosocial burden and strain. These emotional experiences often stem from stressful tasks associated with caregiving. Caregiving supportive services that provide assistance for stressful tasks are instrumental in alleviating caregiving burden and strain. Research is limited on what types of supportive services caregivers are utilizing by relationship status and their source of information regarding these services. We sought to characterize caregiving supportive services use by caregiver relationship status.

METHODS

We analyzed cross-sectional data from the 2015 National Study of Caregiving limited to caregivers of older adults ≥65 years of age. Caregiver relationship status (i.e., spouse, child, other relative/non-relative) was the independent variable. Type of supportive service and source of information about supportive services were the dependent variables. Bivariate analyses were performed to examine the association with caregiver relationship status and associations between use of caregiving supportive services and caregiver and care recipient characteristics. Among service users, we measured associations between caregiver relationship status, type of supportive services used, and source of information about supportive services.

RESULTS

Our sample consisted of 1871 informal caregivers, 30.7% reported using supportive services. By caregiver relationship status, children had the greatest use of supportive services compared to spouses and other relatives/non-relatives (46.5% vs. 27.6% vs. 25.9%, p = <0.01, respectively). Among users of services, there were no differences in type of services used. Spouses primarily received their information about services from a medical provider or social worker (73.8%, p = <0.001).

CONCLUSION

Our findings highlight the need to ensure that other caregiving groups, such as spouses and other relatives/non-relatives, have access to important supportive services such as financial support. Medical providers and/or social workers should be leveraged and equipped to provide this information and refer to services accordingly.

Catalyzing dementia care through the learning health system and consumer health information technology

To advance care for persons with Alzheimer's disease and related dementias (ADRD), real-world health system effectiveness research must actively engage those affected to understand what works, for whom, in what setting, and for how long-an agenda central to learning health system (LHS) principles. This perspective discusses how emerging payment models, quality improvement initiatives, and population health strategies present opportunities to embed best practice principles of ADRD care within the LHS. We discuss how stakeholder engagement in an ADRD LHS when embedding, adapting, and refining prototypes can ensure that products are viable when implemented. Finally, we highlight the promise of consumer-oriented health information technologies in supporting persons living with ADRD and their care partners and delivering embedded ADRD interventions at scale. We aim to stimulate progress toward sustainable infrastructure paired with person- and family-facing innovations that catalyze broader transformation of ADRD care.

The Role of Dementia and Residential Service Agency Characteristics in the Care Experiences of Maryland Medicaid Home and Community-Based Service Participants and Family and Unpaid Caregivers

In Maryland, residential service agencies deliver Medicaid Home and Community-Based Services (HCBS) to older adults with disabilities through direct care workers (e.g., personal care aides). Leveraging survey data from residential service agency administrators, linked to interRAI Home Care assessments for 1144 participants, we describe agency characteristics, and participant and family caregiver experiences by participant dementia status. Most (61.7%) participants experienced low social engagement, and roughly 10.0% experienced a hospitalization or emergency room visit within 90 days. Few (14.4%) participants were served by agencies requiring dementia-specific direct care worker training, and most were served by agencies offering supplemental services, or in which direct care workers helped with health information technology (81.2% and 72.8%, respectively). Few caregivers reported negative care experiences. Participants with dementia and those served by agencies with training and support more often reported negative care experiences. Findings lay the foundation for future longitudinal and embedded interventions within Medicaid HCBS.

Use of provider-sponsored patient portals among older adults and their family caregivers

BACKGROUND

Millions of older adults co-manage or delegate health responsibilities to one or more family caregivers. Patient portals facilitate health care management tasks, but little is known about portal use arrangements (i.e., individual or joint use) among older adults and their caregivers.

METHODS

We sought to characterize individual and joint use of the patient portal and to identify how using arrangements varies by individual-, interpersonal-, and community-level factors. We used linked 2017 National Health and Aging Trends Study, National Study on Caregiving, and American Community Survey data for a nationally representative sample of older adults (n = 1417; weighted n = 7.4 million) and their caregivers (n = 2232; weighted n = 20.6 million). Patient portals used by older adults and caregiver(s) were assessed via self-reports. We described portal use arrangements and tested for between-group differences using weighted Wald tests. Caregiver's likelihood of accessing the portal was modeled using weighted, multivariable logistic regression.

RESULTS

One in ten (10%) community-living older adults were sole portal users, 3% were joint users with one or more caregivers, 14% solely relied on one or more caregivers as portal users, and 74% reported no portal use. Older adults whose portal was only used by caregiver(s) were more likely to be Medicaid-enrolled (20% vs. 1%; p < 0.001), have dementia (43% vs. 5%; p < 0.001), and be homebound (65% vs. 27%; p < 0.001). Caregivers were more likely to use the portal if they were college-educated adjusted odds ratio (aOR): 1.68; p < 0.01) and reported caregiving-related emotional difficulty (aOR: 1.92; p < 0.001) and doing more than their "fair share" (aOR: 1.48; p = 0.03), and were less likely if Black (versus White) (aOR: 0.61; p = 0.01).

CONCLUSIONS

Patient portals could be a valuable platform for identifying and supporting caregivers of high-need older adults, but existing disparities in portal access must be closed to ensure equitable support.

Predictors of falls in older adults with and without dementia

INTRODUCTION

Persons living with, versus without, dementia (PLWD) have heightened fall-risk. Little is known about whether fall-risk factors differ by dementia status.

METHODS

Using the 2015 and 2016 National Health and Aging Trends Study, we prospectively identified fall-risk factors over a 12-month period among community-living older adults ≥65 years with and without dementia (n = 5581).

RESULTS

Fall rates were higher among PLWD compared to persons without dementia (45.5% vs. 30.9%). In a multivariable model including sociodemographic, health, function, and environmental characteristics as predictors, vision impairment (OR: 2.22, 95% CI: 1.12-4.40), and living with a spouse versus alone (OR: 2.43, 95% CI: 1.09-5.43) predicted falls among PLWD, but not among persons without dementia. History of previous falls predicted subsequent falls regardless of dementia status (OR: 6.20, 95% CI: 3.81-10.09, and OR: 2.92, 95% CI: 2.50-3.40, respectively).

DISCUSSION

Incorporating appropriate fall-risk factors could inform effective falls screening and prevention strategies for PLWD.

HIGHLIGHTS

46% of persons with dementia had ≥1 falls versus 31% of those without dementia in 2016. Vision impairment and living with a spouse predicted falls in persons with dementia. Study results support tailored fall prevention strategies for persons with dementia.

Paid Help and Caregiving Experiences of Black Caregivers of Community-Dwelling Older Adults

OBJECTIVES

We examine associations between use of paid help and caregiving-related experiences (emotional, financial, and physical difficulty) of Black family and unpaid caregivers of older adults.

METHODS

We examine a sample of N = 572 non-Hispanic Black caregivers of community-dwelling older adults receiving help with daily activities from the 2015 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC). Guided by Pearlin's Stress Process Model, logistic regression models examine associations between assisting with finding paid help and caregiver experiences.

RESULTS

Black caregivers who helped care recipients find paid help more often had a college degree or higher, were helping older adults who received assistance with three or more self-care/mobility activities or who were living in poverty and were not receiving help with caregiving from family and friends. In fully-adjusted models, assisting with finding paid help was associated with emotional (AOR 1.92, 95% CI 1.27, 2.92 p < .01) and physical (AOR 2.16, 95% CI 1.04, 4.51; p = .04) difficulty.

CONCLUSIONS

Greater efforts are needed to support Black family and unpaid caregivers who are caring for older adults using paid help.

CLINICAL IMPLICATIONS

Future interventions that target Black caregivers of older adults using paid help could be useful for improving caregiving experiences.

Associations Between Use of Paid Help and Care Experiences Among Medicare-Medicaid Enrolled Older Adults With and Without Dementia

OBJECTIVES

Community-living older Medicare and Medicaid enrollees ("dual-enrollees") have high care needs and commonly receive paid and unpaid long-term services and supports (LTSS) to help with routine activities. Little is known about whether receiving paid help or individuals' state and neighborhood environmental context ("LTSS environment") relates to dual-enrollees' care experiences.

METHODS

We examine a sample of n = 979 community-dwelling dual-enrollees with disabilities from 2011 to 2015 National Health and Aging Trends Study, linked to measures of neighborhood disadvantage and state Medicaid home and community-based services (HCBS) generosity. Logistic regression models stratified by dementia status assess associations between paid help and: (a) adverse consequences due to unmet care needs, and (b) participation restrictions in valued activities, among dual-enrollees with and without dementia, adjusting for individual and LTSS environmental characteristics.

RESULTS

Use of paid help was greater for those with (versus without) dementia (46.9% vs. 37.8%). Neighborhood disadvantage was associated with greater use of paid help among dual-enrollees living with dementia. High state Medicaid HCBS generosity was associated with the use of paid help, regardless of dementia status. Dual-enrollees with dementia receiving paid help had higher odds of experiencing adverse consequences due to unmet need (adjusted odds ratio = 2.05; 95% confidence interval 1.16-3.61; p = .02)-no significant associations were observed for participation restrictions. Use of paid help and LTSS environment were not significantly associated with care experiences for dual-enrollees without dementia.

DISCUSSION

Findings highlight the complexities of caring for dual-enrollees, particularly those with dementia, and emphasize the need to strengthen the delivery of paid care with considerations for the LTSS environment.

Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports

Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.

The Influence of Race and Gender on Receiving Assistance with Daily Activities among Older Americans

Background and Objectives

Nearly 8.2 million community-dwelling, older Medicare beneficiaries receive support from long-term services and supports (LTSS) with routine daily activities. Prior work demonstrates disability-related disparities; however, it is unclear whether these patterns persist among LTSS recipients and across specific sets of activities. We examine race and gender differences in receiving help with self-care (e.g., eating), mobility (e.g., getting around the house), and household (e.g., shopping) activities in a nationally representative sample of community-dwelling Medicare beneficiaries receiving LTSS.

Research Design and Methods

Cross-sectional analysis of 1,808 White and Black older adults receiving assistance with routine daily activities in the 2015 National Health and Aging Trends Study. Bivariate statistics were used to describe the sample and provide comparisons of characteristics by race and gender. Logistic regression models examined race and gender differences in receiving assistance with self-care, mobility, and household activities after adjusting for sociodemographic and health characteristics.

Results

Race and gender differences were observed across all sociodemographic and health characteristics, as well as for all forms of assistance. Relative to White men, Black men had lower odds of receiving help with self-care activities. White and black women had higher odds and Black men had lower odds of getting help with mobility activities than White men. Black men and White and Black women all had higher odds of receiving assistance with household tasks compared to White men.

Discussion and Implications

Our findings indicate that, despite prior evidence of disability-related disparities, the receipt of help with self-care, mobility, and household activities varies by race and gender. Findings reveal several target areas for future research. Future work should examine the role of cultural and social preferences for care, as well as the appropriateness of help, as evidenced by health service use and changes in quality of life.

Systematic Review and Meta-Analysis of Racial and Ethnic Differences in Dementia Caregivers' Well-Being

BACKGROUND AND OBJECTIVES

Studies comparing racial/ethnic differences on measures of psychological and physical well-being for dementia caregivers have reported differences between minority and white caregivers. Recruitment methods often differ for minority and white participants due to enrollment targets and may lead to biased comparisons, especially in convenience samples. We aimed to examine racial/ethnic differences in dementia caregiver outcomes and to determine whether differences vary between studies with population-based or convenience samples.

RESEARCH DESIGN AND METHODS

We systematically reviewed articles with primary data from PubMed, Google Scholar, and PsycINFO. We included studies comparing African American or Hispanic/Latino to white dementia caregivers on measures of psychological well-being or physical well-being. Reviewers screened titles and abstracts, reviewed full texts and conducted risk-of-bias assessments. Meta-analyses were conducted to assess effects by race/ethnicity and study bias.

RESULTS

A total of 159 effects were extracted from 38 studies, 2 of which were population based. Random-effects models revealed small but statistically significant effects with better psychological well-being in African American caregivers compared with white caregivers in both population-based (d = -0.22) and convenience sample studies (d = -0.21). Hispanics/Latino caregivers reported lower levels of physical well-being than white caregivers (d = 0.12), though these effects varied by level of rated study bias.

DISCUSSION AND IMPLICATIONS

Consistency across study methods raises confidence in the validity of previous reports of better psychological well-being in African American caregivers. Future studies should use population-based samples with subgroups of Hispanic/Latino, Asian American, and American Indian caregivers that are culturally distinct on factors such as country of origin and tribe.

Neighborhood Broadband and Use of Telehealth Among Older Adults: Cross-sectional Study of National Survey Data Linked With Census Data

Background

The COVID-19 pandemic has amplified the role of telehealth in health care delivery. Regional variation in internet access and telehealth use are well-documented, but the effect of neighborhood factors, including the pervasiveness of broadband internet, on older adults’ telehealth usage in the context of internet access is not known.

Objective

This study aimed to investigate how individual and neighborhood characteristics, including the pervasiveness of neighborhood broadband internet subscription, are associated with engagement in telehealth among older adults with internet access.

Methods

In this cross-sectional study, we included 5117 community-living older adults aged ≥65 years, who participated in the 2017 National Health and Aging Trends Study with census tract–level data for participants’ places of residence from the American Community Survey.

Results

Of an estimated 35.3 million community-living older adults, 21.1 million (59.7%) were internet users, and of this group, more than one-third (35.8%) engaged in telehealth. In a multivariable regression model adjusted for individual- and neighborhood-level factors, age, education, income, and the pervasiveness of neighborhood broadband internet subscription were associated with engagement in telehealth, while race, health, county metropolitan status, and neighborhood social deprivation were not. Among internet users, living in a neighborhood at the lowest (versus highest) tertile of broadband internet subscription was associated with being 40% less likely to engage in telehealth (adjusted odds ratio 0.61, 95% CI 0.42-0.87), all else equal.

Conclusions

Neighborhood broadband internet stands out as a mutable characteristic that is consequential to engagement in telehealth.

Race Differences in Characteristics and Experiences of Black and White Caregivers of Older Americans

BACKGROUND AND OBJECTIVES

Racial disparities in health and socioeconomic characteristics of older adults have implications for the experiences of their family and unpaid caregivers, but knowledge to date has primarily drawn from convenience samples. Using a population-based sample, we examine associations between caregiver race and caregiving-related effects.

RESEARCH DESIGN AND METHODS

Study participants include white (n = 992) and black (n = 556) respondents to the 2015 National Study of Caregiving who assisted community-dwelling older adults with disabilities who participated in the National Health and Aging Trends Study. Guided by Pearlin's Stress Process Model, hierarchical logistic regression models were constructed to examine race differences in caregiving-related effects after adjusting for caregiving context, stressors, and resources.

RESULTS

Relative to white caregivers, blacks more often provided in excess of 40 hr of care per week (54.3% vs 38.6%) and more often cared for an older adult with dementia (27.1% vs 20.7%) who was living below the federal poverty line (31.7% vs 11.9%) or was Medicaid-eligible (42.2% vs 11.8%). Black caregivers more often used supportive services (32.9% vs 24.8%). In fully adjusted regression models, black caregivers were more likely to report gains and less likely to report emotional difficulty than whites. Service utilization did not attenuate caregiving-related emotional difficulty or participation restrictions, regardless of race.

DISCUSSION AND IMPLICATIONS

Findings highlight caregiving disparities and counterintuitive differences in experiences and indicate the importance of identifying supports such as paid family leave and faith and community-based programming to better support community-dwelling low-income older adults and their family and unpaid caregivers.

Patterns and Predictors of Transitions Across Residential Care Settings and Nursing Homes Among Community-Dwelling Older Adults in the United States

BACKGROUND AND OBJECTIVES

Older adults prefer to age in place, but sociodemographic, health, and socioeconomic factors may influence their decision to remain in the community. Guided by Andersen's behavioral model, we characterize incident transitions out of the community into residential care settings or nursing homes and identify predictors of these transitions.

RESEARCH DESIGN AND METHODS

Study participants include 2,725 (weighted n = 13,704,390) community-dwelling U.S. older adults of the National Health and Aging Trends Study from 2011 to 2018. We examined the associations between sociodemographic, socioeconomic, and health factors and the probability of transition using a multinomial logit model.

RESULTS

Over the study period, 86.2% of older adults remained in the community, whereas 9.0% and 4.9% transitioned to residential care settings and nursing homes, respectively. Older age, living alone, having functional and cognitive limitations, and hospitalization were associated with increased risk of transitioning to residential care settings or nursing homes from the community. Blacks and Hispanics were less likely to transition to residential care settings or nursing homes. Adults with lower income had a greater risk of transitioning to nursing homes. Medicaid enrollment did not affect the likelihood of transition.

DISCUSSION AND IMPLICATIONS

Majority of older adults remained in the community, and incident transition to residential care settings was more common than to nursing homes. Policy should target sociodemographic, health, and socioeconomic factors that enable older adults to age in place. Future work should examine whether these new residential care settings enhance the quality of life or result in subsequent transitions back into the community.

Receipt of Posthospitalization Care Training Among Medicare Beneficiaries' Family Caregivers

Importance

Medicare conditions of participation require hospitals to provide training to family and unpaid caregivers when their support is necessary to enact the postdischarge care plan. However, caregivers often report feeling unprepared for this role.

Objective

To describe the characteristics of caregivers who assist with posthospitalization care transitions and assess the prevalence of and factors associated with receipt of adequate transitional care training.

Design, Setting, and Participants

This cross-sectional study analyzed data from the 2017 National Health and Aging Trends Study and its linked National Study of Caregiving, surveys of Medicare beneficiaries and their family and unpaid caregivers. The present study included family caregivers for community-living Medicare beneficiaries 65 years or older with disabilities. Data analysis was performed from June to September 2020.

Main Outcomes and Measures

Characteristics of family caregivers by whether they assisted during a posthospitalization care transition in the year preceding the survey interview. Unweighted frequencies and weighted percentages, as well as the results of weighted Pearson and Wald tests for differences between groups, are reported. Receipt of the training needed to manage the older adult's posthospitalization care transition (hereafter referred to as adequate transitional care training) as a function of individual caregiver characteristics was modeled using multivariable, weighted logistic regression.

Results

Of 1905 family caregivers, 618 (58.9%) were 60 years or older, 1288 (63.8%) were female, and 796 (41.7%) assisted with a posthospitalization care transition. Those who assisted with a posthospitalization care transition were more likely to report experiencing financial (154 [18.3%] vs 123 [10.1%]; P < .001), emotional (344 [41.3%] vs 342 [31.1%]; P < .001), and physical (200 [22.2%] vs 170 [14.6%]; P = .001) difficulty associated with caregiving. Among caregivers who assisted during a posthospitalization care transition, 490 (59.1%) reported receiving adequate transitional care training. Caregivers were less likely to report receiving adequate training if they assisted an older adult who was female (316 [62.3%] vs 227 [73.2%]; P = .02), Black (163 [14.0%] vs 121 [19.8%]; P = .02), or enrolled in Medicaid (127 [21.2%] vs 90 [31.9%]; P = .01). After adjusting for older adult characteristics, caregivers were half as likely to report receiving adequate training if they were Black (adjusted odds ratio [aOR], 0.52; 95% CI, 0.31-0.89) or experienced financial difficulty (aOR, 0.50; 95% CI, 0.31-0.81). Caregivers were more than twice as likely to report receiving adequate training if they were female (aOR, 2.44; 95% CI, 1.65-3.61) or spoke with the older adult's clinician about his or her care in the past year sometimes or often vs never (aOR, 1.93; 95% CI, 1.19-3.12).

Conclusions and Relevance

In this cross-sectional study, caregivers were less likely to receive adequate transitional care training if they were Black; experienced financial difficulty; or cared for a Black, female, or Medicaid-enrolled older adult. These findings suggest that changes to the discharge process, such as using standardized caregiver assessments, may be necessary to ensure equitable support of family caregivers.

State Medicaid Financing and Access to Large Assisted Living Settings for Medicare-Medicaid Dual-Eligibles

Assisted living has become more widely used by dual-eligible Medicare beneficiaries as states try to rebalance their long-term services and supports away from institutional (nursing home) care. In an analysis of 2014 Medicare data for 506,193 adults who live in large (25+ beds) assisted living communities, we found wide variability among states in the share of assisted living residents who were dual-eligible, ranging from 6% in New Hampshire to over 40% in New York. This variation is strongly correlated with the Medicaid support for assisted living care: In states with a Medicaid state plan option covering services in assisted living or both a state plan and waiver, the percent of assisted living residents with dual-eligibility was more than 10 percentage points higher than in states with neither a state plan nor waiver. Findings provide a basis for understanding the role of Medicaid financing in access to assisted living for duals.

A New Stage of the Caregiving Career: Informal Caregiving After Long-Term Institutionalization

BACKGROUND AND OBJECTIVES

The "unexpected career" of caregiving has previously been conceptualized in stages: community care through institutional placement/residence, ending with death of the care recipient. Transition programs such as Money Follows the Person (MFP) created a new stage of the caregiving career, caring for someone post-long-term institutionalization, about which little is known. Using Pearlin's Caregiver Stress Process Model, this study explores effects on caregivers from the return of their loved ones to the community after a long-term institutional stay.

RESEARCH DESIGN AND METHODS

Cross-sectional surveys of 656 caregivers of persons transitioned through Connecticut's MFP program 2014-18, completed 6 months post-transition.

RESULTS

Regardless of the age/disability of the care recipient, and despite experiencing high caregiving intensity, caregivers experienced less burden, anxiety, and depression, and higher benefits of caregiving than demonstrated in literature for the general caregiving population. Most felt less stressed than before and during the participant's institutional stay. Factors associated with worse outcomes included worry about safety, strained finances, missing work, and desiring additional services. Black and Hispanic caregivers experienced lower burden and anxiety and higher benefits of caregiving than White caregivers.

DISCUSSION AND IMPLICATIONS

By providing community supports to participants, transition programs can have broad ancillary benefits for caregivers and improve outcomes in the Pearlin model, lessening potentially deleterious effects of an unexpected return to intensive caregiving duties after institutional placement. Positive results for Black and Hispanic caregivers may reflect cultural expectations in caring for family that buffer the adverse effects of caregiving.

Quality of Post-Acute Care in Skilled Nursing Facilities That Disproportionately Serve Hispanics With Dementia

OBJECTIVES

As the number of Hispanics with dementia continues to increase, greater use of post-acute care in nursing home settings will be required. Little is known about the quality of skilled nursing facilities (SNFs) that disproportionately serve Hispanic patients with dementia and whether the quality of SNF care varies by the concentration of Medicare Advantage (MA) patients with dementia admitted to these SNFs.

DESIGN

Cross-sectional study using 2016 data from Medicare certified providers.

SETTING AND PARTICIPANTS

Our cohort included 177,396 beneficiaries with probable dementia from 8884 SNFs.

METHODS

We examined facility-level quality of care among facilities with high and low proportions of Hispanic beneficiaries with probable dementia enrolled in MA and fee-for-service (FFS) using data from Medicare-certified providers. Three facility-level measures were used to assess quality of care: (1) 30-day rehospitalization rate; (2) successful discharge from the facility to the community; and (3) Medicare 5-star quality ratings.

RESULTS

About 20% of residents were admitted to 1615 facilities with a resident population that was more than 15% Hispanic. Facilities with a higher share of Hispanic residents had a lower proportion of 4- or 5-star facilities by an average of 14% to 15% compared with facilities with little to no Hispanics. In addition, these facilities had a 1% higher readmission rate. There were also some differences in the quality of facilities with high (>26.5%) and low (<26.5%) proportions of MA beneficiaries. On average, SNFs with a high concentration of MA patients have lower readmission rates and higher successful discharge, but lower star ratings.

CONCLUSIONS AND IMPLICATIONS

Achieving better quality of care for people with dementia may require efforts to improve the quality of care among facilities with a high concentration of Hispanic residents.

Change in Social Engagement among Incident Caregivers and Controls: Findings from the Caregiving Transitions Study

Objectives:We aimed to compare incident family caregivers and matched controls on change in social network variables and satisfaction with social activities. Methods: A total of 479 participants from the Caregiving Transitions Study were included in the analysis, 244 (50.9%) of whom began substantial and sustained caregiving between baseline and follow-up interviews. We assessed associations between incident caregiving and change in social network size, change in monthly social contact, and satisfaction with social activities. Results: Incident caregivers reported lower satisfaction with social activities and greater decline in social network size than controls. Among only the caregivers, dementia caregivers reported greater decline in social network size while caregivers who were spouses, experienced higher strain, and provided more hours of care reported lower satisfaction with social activities. Discussion: Social engagement declined more among incident caregivers than controls. Future studies should aim to understand why subgroups of caregivers reported lower social engagement.

Racial Differences in Respite Use among Black and White Caregivers for People Living with Dementia

Objectives: To examine racial differences in respite utilization among a nationally representative sample of caregivers for persons living with dementia (PLwD). A secondary aim identified factors associated with respite utilization. Methods: Using data from the 2015 National Health and Aging Trends Study and National Study of Caregiving, we conducted binary logistic regression to examine racial difference in respite use among Black and white caregivers ( n = 750). Results: 22% of the sample used respite for PLwD. Black dementia caregivers were 69% less likely (odds ratio: .31, p = .001) to use respite compared to white caregivers. Other factors associated with utilization included education, receiving help with caregiving, and providing care for more self-care/mobility tasks or to a Medicaid-enrollee. Discussion: Findings suggest that Black dementia caregivers may be at risk for less frequent use of respite and highlight the need to identify factors that promote respite use.

Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort

IMPORTANCE

Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain.

OBJECTIVE

To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death.

DESIGN, SETTING, AND PARTICIPANTS

This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020.

MAIN OUTCOMES AND MEASURES

The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records.

RESULTS

The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents.

CONCLUSIONS AND RELEVANCE

Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.

SYSTEMATIC REVIEW AND META-ANALYSIS OF RACIAL AND ETHNIC DIFFERENCES IN DEMENTIA CAREGIVER WELL-BEING

Studies comparing racial/ethnic differences on psychological and physical outcomes of dementia caregivers have often reported differences in well-being for minority groups compared to Whites. However, due to issues with enrolling minorities into studies, recruitment methods often differ for minority and White participants and may lead to biased comparisons. We conducted a systematic review and meta-analysis to examine racial/ethnic differences in dementia caregiver outcomes and to determine whether any differences vary among studies with population-based samples compared to convenience samples. We systematically reviewed articles with primary data from PubMed, Google Scholar and PsycINFO, and included studies comparing either African American (AA) or Hispanic/Latino dementia caregivers to White caregivers on measures of psychological health (e.g. depression, anxiety, burden) and physical health (e.g. self-rated health, cardiovascular measures, stress biomarkers). Reviewers screened titles and abstracts, reviewed full texts and conducted risk-of-bias assessments. A total of 207 effects were extracted from 40 studies. Random-effects models showed that Hispanics/Latinos reported significantly lower levels of well-being than Whites (ps < .05) for both psychological outcomes (37 effects) and physical outcomes (15 effects), while AAs were not significantly different from Whites in either domain. No differences were observed for population-based studies (N=3; 23 effects) or convenience-sample studies (N=37; 184 effects). Although some previous studies with convenience samples found better psychological well-being in AA caregivers, that pattern was not confirmed in our meta-analysis. Additional analyses for the different indicators of well-being and the relationship of quality ratings to effect sizes will be discussed along with implications for future research.

RACIAL DISPARITIES IN COMMUNITY- AND INSTITUTION-BASED LONG-TERM SERVICES AND SUPPORTS

Long-term services and supports (LTSS) are services provided to individuals with functional limitations and chronic conditions who need assistance to perform daily activities such as bathing, dressing, preparing meals, and administering medications, and can be provided in community settings via services such as home health, as well as institutions such as nursing homes. Racial disparities are persistent across systems of LTSS, with older adults of color receiving lower quality care and experiencing worse health outcomes than their white counterparts. Given the increasing diversity of the aging population, and the need to ensure equity in quality and health outcomes in LTSS, there is a greater need for more understanding of how experiences of care vary across multiple settings for diverse groups of older adults and the people who help them. This symposium will feature 5 presentations that provide novel insight regarding racial disparities in community- and institution-based LTSS. We focus on racial differences in functional needs and disparities among those receiving home health services and living in nursing homes. Individual presentations will describe 1) race and gender differences in physical functioning needs of older adults; 2) disparities in home health quality across racially diverse and low income geographic areas; 3) racial disparities in nursing home residents overtime; 4) racial and ethnic disparities in rates of 30-day rehospitalization from skilled nursing facilities among Medicare Fee-For-Service and Medicare Advantage patients; and 5) the impact of the unequal burden of care provided to minority nursing home residents by staff of color.

GENDER DIFFERENCES IN RECEIVING ASSISTANCE WITH DAILY CARE NEEDS AMONG OLDER BLACK AMERICANS LIVING WITH DIABETES

Older Black Americans living with diabetes often receive social support critical to their self-care management practices and quality of life. Studies have reported positive relationships between support and diabetes care among this population, although gender differences exist, with men reporting better quality of life outcomes associated with diabetes self-management than women. More information is needed to to assist healthcare providers indeveloping gender-tailored interventions to improve diabetes self-management. Using data from the 2015 National Health and Aging Trends Study (NHATS; Round 5), a nationally representative sample of Medicare beneficiaries aged 65 and older, our cross-sectional study describes gender differences in receiving assistance with self-care, mobility, and household needs among older Black adults with diabetes (N=621). Participants were majority female (59% Females; 41%Males). Bivariate analyses showed women were often older with fewer years of education, lower incomes, and were more likely to live with others than men. A larger share of respondents reported receiving assistance with household activities (34%; e.g. shopping, medication administration), followed by self-care (21%; e.g. bathing, dressing), and mobility tasks (17%; e.g. getting around inside and outside of the house). Binary logistic regression showed that women were more likely to report receiving assistance with all three tasks after adjusting for age, education, income, living arrangements, number of health conditions, and self-rated health. Future research should identify the relationships between caregivers and care recipients (e.g. spouse/partner, children), as receiving support with daily needs has the potential to impact both the health and quality of life of both caregivers and care-recipients.

RACE AND GENDER DIFFERENCES IN PHYSICAL FUNCTIONING AMONG COMMUNITY-DWELLING OLDER ADULTS

Prior work has demonstrated that there are race and gender disparities in the prevalence of need for assistance with tasks such as self-care, mobility, and household activities. Research has historically shown that older black Americans and women experience greater prevalence of physical functioning declines. It is unclear whether these differences persist among those receiving assistance. Using data from the 2015 National Health and Aging Trends Study (NHATS), a nationally representative study of Medicare beneficiaries aged 65 and older, and after adjusting for covariates, black men received less assistance with self-care and mobility activities, and white and black women received more help with mobility and household activities, compared to white men. Findings are critical to advancing our understanding of the needs of vulnerable older adults receiving assistance. More research is needed to understand the implications of these differences on long-term services and supports provided by both informal and formal caregivers.

MEDICAID FINANCING IN ASSISTED LIVING AND CHARACTERISTICS OF MEDICARE DUAL-ELIGIBLE RESIDENTS

An increasing number of assisted living (AL) residents rely on Medicaid waivers or state plans to pay for personal care and other supportive services. States may finance services for duals residing in AL through Medicaid waivers and state plans, but the availability of coverage varies – some states offer little to no Medicaid coverage for services in AL, and others offer multiple pathways to receiving assistance. Little is known about duals in AL, including how many have access to AL and the quality of care they receive there. The present study compares the characteristics of Medicare beneficiaries residing in large AL settings, by dual-eligibility status, and investigates the variability in the share of duals in AL among states. We identified 586,397 Medicare beneficiaries residing in AL in 2014. Medicare claims were used to measure health characteristics and health care utilization. Duals represented 16% of AL residents in our cohort. Compared to non-duals, duals were more often older adults of color (24 vs 4%), and more likely to qualify for Medicare due to disability (46 vs 7%). Duals had higher rates of hospitalizations (24 vs 21%) and skilled nursing facility use while in AL (11 vs 10%), and more chronic conditions than non-duals. States varied in the share of AL residents who are duals, ranging from 6% in New Hampshire to 41% in New York. State policies that may contribute to variation in the prevalence of duals in AL and implications of these findings for policy-makers and residents will be discussed.

RACIAL DIFFERENCES IN CHARACTERISTICS AND PERCEPTIONS OF CAREGIVERS TO BLACK AND WHITE OLDER ADULTS

Persistent racial differences in health, socioeconomic characteristics, and service utilization of older adults likely result in differential effects for the circumstances and experiences of family and unpaid caregivers. Utilization of community-based services has been found to alleviate caregiver burden, but the extent to which supports and informal help affect race differences in caregiver perceptions (e.g. positive/negative feelings associated with caregiving) and engagement in activities such as religious services, volunteering, or visiting family and friends, is less understood. Using data from the 2015 National Health and Aging Trends Study (NHATS; Round 5) and the National Study of Caregiving (NSOC; Round 2), nationally representative studies of Medicare beneficiaries aged 65 and older and their caregivers, this presentation will discuss the association between sociodemographic characteristics, use of assistance from others or supportive services, and perceived gains, difficulties, and social engagement among caregivers to older black and white adults.

Racial Differences in Choice and Control Among Older Adults: Results From Connecticut's Money Follows the Person Rebalancing Demonstration

We examined racial differences in determinants of choice and control in daily activities and service coordination for a sample of White and Black participants in the Connecticut Money Follows the Person (MFP) Rebalancing Demonstration. Within-group analyses were conducted to understand factors that contribute to choice and control among participants. While no disparities were found in the odds of reporting choice and control, our findings show that White participants with mental health challenges, who lived with family, and had more functional impairments and Black participants with engagement transition challenges were less likely to have choice and control over daily activities. Determinants varied by race for choice in service coordination. Findings indicate a need for initiatives to target different factors for White and Black MFP participants to optimize opportunities for choice and control after returning to community living.

Examining Black-White Disparities Among Medicare Beneficiaries in Assisted Living Settings in 2014

OBJECTIVE

Assisted living (AL) provides housing and personal care to residents who need assistance with daily activities. Few studies have examined black-white disparities in larger (25 + beds) ALs; therefore, little is known about black residents, their prior residential settings, and how they compare to whites in AL. We examined racial differences among a national cohort of AL residents and how the racial variation among AL Medicare Fee-For-Service (FFS) beneficiaries compared to differences among community-dwelling and nursing home cohorts.

STUDY DESIGN

Retrospective cohort study.

PARTICIPANTS

We included (1) a prevalence sample of 442,018 white and black Medicare beneficiaries residing in large AL settings, (2) an incidence sample of new residents (n = 94,741), and (3) 10% random samples of Medicare FFS community-dwelling and nursing home beneficiaries in 2014.

MEASURES

The Medicare Master Summary Beneficiary File was used to identify AL residents and provided demographic, entitlement, chronic condition, and health care utilization information. We used the American Community Survey and prior ZIP code tabulation areas of residents to examine differences in prior neighborhoods. Medicare claims and the Minimum Data Set yielded samples of Medicare FFS community-dwelling older adults and nursing home residents.

RESULTS

Blacks were disproportionately represented in AL, younger, more likely to be Medicaid eligible, had higher levels of acuity, and more often lived in ALs with fewer whites and more duals. New black residents entered AL with higher rates of acute care hospitalizations and skilled nursing facility utilization. Across the 3 cohorts, blacks had higher rates of dual-eligibility.

CONCLUSIONS

Black-white differences observed among AL residents indicate a need for future work to examine how disparities manifest in differences in care received and residents' outcomes, as well as the pathways to AL. More research is needed to understand the implications of inequities in AL as they relate to quality and experiences of residents.

Racial disparities in Medicaid home and community-based service utilization and expenditures among persons with multiple sclerosis

BACKGROUND

Medicaid home and community-based services (HCBS) provide services such as personal care, nursing, and home-delivered meals to aging adults and individuals with disabilities. HCBS are available to people across racial and ethnic groups, yet racial disparities in Medicaid HCBS utilization and expenditures have been understudied. Individuals with multiple sclerosis (MS) may be particularly impacted by HCBS, as nearly one-third requires assistance at home. The present study examined whether disparities exist in Medicaid HCBS utilization and expenditures among HCBS users with MS.

METHODS

We used secondary data to conduct a retrospective cohort analyses including 7550 HCBS recipients with MS. Demographic data was obtained from the Medicaid Analytic eXtract Personal Summary file, Medicaid HCBS service utilization and expenditures were obtained from the Other Therapy file, and comorbidities from the Medicare Chronic Condition Warehouse. Univariate and bivariate statistics were used to describe the sample and provide comparisons of characteristic by race. Logistic regression predicted the likelihood of using HCBS type and gamma regression was used to predict Medicaid HCBS expenditures.

RESULTS

Black HCBS users were younger, more likely to be female, and were more impaired than Whites. Multivariate analyses showed that Blacks were less likely to receive case management, equipment, technology and modification services, and nursing services compared to Whites. Additionally, Black men had the lowest Medicaid HCBS expenditures, while White men had the highest.

CONCLUSIONS

Findings shed light on disparities among HCBS users with MS. As Blacks are already disproportionately affected by MS, these results reveal target areas for future research. Future work should examine the factors that contribute to these disparities, as well as determine the extent to which these inequities impact outcomes such as hospitalizations and nursing home admissions.

Health Care Discrimination, Sex Behavior Disclosure, and Awareness of Pre-Exposure Prophylaxis Among Black Men Who Have Sex With Men

Background

Perceived healthcare-related discrimination and disclosure of same-sex sex behaviors to healthcare providers may act as barriers to awareness of pre-exposure prophylaxis (PrEP) for Black/African-American men who have sex with men (BMSM). Given the elevated rates of HIV transmission among young BMSM in particular, age is likely an important factor for determining the correlates of PrEP awareness unique to BMSM of different ages.

Method

147 BMSM (M age = 30.6 years, SD = 10.3 years) located in the Southeastern United States were recruited from gay-identified bars, clubs, bathhouses, parks, and street locations, via online classifieds (e.g., Craigslist) and social media (e.g., Facebook). Participants completed surveys that included questions about demographic characteristics, perceived healthcare-related discrimination, disclosure of same-sex sex behavior to healthcare providers, and PrEP awareness.

Results

Perceived healthcare-related discrimination was significantly, negatively associated with PrEP awareness, and same-sex sex behavior disclosure to healthcare providers was significantly, positively related to awareness of PrEP among BMSM. A moderation analysis, with participant age as the moderator, revealed that higher perceived healthcare-related discrimination was significantly, negatively associated with PrEP awareness beginning at 30.2 years of age, and that the relationship strengthened as age increased.

Discussion

Perceived healthcare-related discrimination plays a particularly important role in PrEP awareness for BMSM who are 30 years of age and older. Discrimination in healthcare settings may impact BMSM's ability, particularly those who are older, to access PrEP information. Healthcare professionals must establish procedures for identifying appropriate patients for PrEP, and prioritize addressing the psychosocial factors that impede PrEP awareness for their BMSM patients.

Differences in Living Arrangements Among Older Adults Transitioning Into the Community: Examining the Impact of Race and Choice

The federal Money Follows the Person Rebalancing Demonstration program allows nursing home residents to use Medicaid funds for home and community-based services rather than institutional care. Race, choice in housing, and challenges faced prior to transitioning may impact living arrangements following a discharge into the community. This study examines the influence of these factors on living arrangements for 659 program participants age 65 or older. Unmarried Blacks and people with financial or legal challenges are less likely to live with a live-in caregiver or in supervised housing compared with unmarried Whites. Race did not determine living arrangements among married participants, but housing transition challenges did. Findings inform policies targeting nursing home rebalancing efforts by highlighting racial diversity in living arrangements and emphasizing the need for affordable, accessible housing options for older adults of any race seeking to live in the community rather than remain in an institutional setting.