A protocol for stakeholder engagement in deliver-EE: A pragmatic randomized comparative effectiveness trial evaluating effects of meal delivery on the ability of homebound older adults to remain in the community

BACKGROUND

Few clinical trials include a detailed protocol for stakeholder engagement in the design and execution of the clinical trial. Deliver-EE is a pragmatic clinical trial to assess how different types of home-delivered meals can affect older adults' health and well-being. We present the protocol for stakeholder engagement in this national, multi-site trial and initial findings from our efforts.

METHODS

Twenty-nine participants were recruited to two stakeholder advisory panels. The "Lived Experience Perspectives" panel is defined as the clients, caregivers, and meal delivery drivers with first-hand knowledge and lived experiences with meal delivery. The "System Perspectives" panel is defined as representatives from the larger financial, clinical, regulatory, and operational environments in which meal delivery to homebound older adults operate. Together, these two groups holistically represent interested parties that coordinate the interdependent elements of meal delivery to homebound older adults in order to: 1) inform our understanding of what matters most to older adults, their families, and the larger health and social care systems; 2) provide strategies to overcome challenges conducting the study; 3) enhance dissemination and uptake of study findings; and 4) identify opportunities for future research.

RESULTS

Although stakeholder partners share a common goal of using home-delivered meals as a method to improve outcomes for homebound older adults, individuals have different goals for participating as advisors in this research.

CONCLUSIONS

Understanding what individual stakeholders hope to gain from their participation is critical in designing an effective engagement protocol and critical for meaningful and rigorous stakeholder engagement in clinical trials.

Caring for nursing home residents with dementia during the COVID-19 pandemic: Perspectives from administrators

See related Editorial by Unroe and Towsley in this issue.

Administrator Perspectives on the Impact of COVID-19 on the Administration of the Patient Driven Payment Model in U.S. Skilled Nursing Facilities

The Patient Driven Payment Model (PDPM) was implemented in U.S. skilled nursing facilities (SNFs) in October 2019, shortly before COVID-19. This new payment model aimed to reimburse SNFs for patients' nursing needs rather than the previous model which reimbursed based on the volume of therapy received. Through 156 semi-structured interviews with 40 SNF administrators from July 2020 to December 2021, this qualitative study clarifies the impact of COVID-19 on the administration of PDPM at SNFs. Interview data were analyzed using modified grounded theory and thematic analysis. Our findings show that SNF administrators shifted focus from management of the PDPM to COVID-19-related delivery of care adaptations, staff shortfalls, and decreased admissions. As the pandemic abated, administrators re-focused their attention to PDPM. Policy makers should consider the continued impacts of the pandemic at SNFs, particularly on delivery of care, admissions, and staffing, on the ability of SNF administrators to administer a new payment model.

Implementing the Patient Driven Payment Model-Perspectives from Skilled Nursing Facility Administrators

Objective: To explore skilled nursing facility (SNF) administrator retrospective perspectives on their preparation for and initial implementation of the Patient Driven Payment Model (PDPM), the new Medicare payment system for SNFs enacted on October 1, 2019. Methods: 156 interviews at 40 SNFs in eight U.S. markets were conducted and qualitatively analyzed. Results: Administrators retrospectively expressed feeling well-prepared for the PDPM implementation. Advance preparation focused on training staff regarding patient assessment and documentation. Administrators also recognized increased incentives for admitting patients with more complex needs and prepared accordingly. Therapy staffing reductions were concentrated in contract employees, while SNF-employed therapists were less affected. Conclusion: Policy makers and industry experts should consider the long-term impact of changing financial incentives through payment reform, and ensure that reimbursement best reflects the cost of providing services while prioritizing high-quality care. PDPM's effect on care quality and access to care should continue to be monitored.

COVID-19 Vaccination Among Skilled Nursing Facility Staff: Challenges and Strategies Identified by Administrators

COVID-19 vaccinations are critical for mitigating outbreaks and reducing mortality for skilled nursing facility (SNF) residents and staff, yet uptake among SNF staff varies widely and remains suboptimal. Understanding which strategies are successful for promoting staff vaccination, and examining the relationship between vaccination policies and staff retention/turnover is key for identifying best practices. We conducted repeated interviews with SNF administrators at 3-month intervals between July 2020 and December 2021 (n = 156 interviews). We found that COVID-19 vaccines were initially met with both enthusiasm and skepticism by SNF staff. Administrators reported strategies to increase staff vaccine acceptance, including incentives, one-on-one education, and less stringent personal protective equipment requirements. Federal and state vaccination mandates further promoted vaccine uptake. This combination of mandates with prioritization of the vaccine by SNFs and their leadership was successful at increasing staff vaccination acceptance, which may be critical to increase staff booster uptake from its current suboptimal levels.

Identifying strategies that promote staff and resident influenza and COVID-19 vaccination in nursing homes: Perspectives from nursing home staff

Resident and staff influenza and COVID-19 vaccination are critical components of infection prevention in nursing homes. Our study sought to characterize strategies that nursing home staff use to promote vaccination. Twenty-six telephone/videoconference interviews were conducted with administrators, directors of nursing, infection preventionists, and Minimum Data Set coordinators at 14 nursing homes across the US. Transcripts were analyzed using content analysis and a detailed audit trail was maintained. Staff described resident and staff influenza and COVID-19 vaccine hesitancy and confidence as well as varying approaches to promote vaccination. These included incentives, education efforts, and having a "vaccine champion" responsible for vaccine promotion. While many strategies had been in place prior to COVID-19 in support of improving influenza vaccination, participants reported implementing additional approaches to promote COVID-19 vaccination. Findings may inform future efforts to promote vaccination, which will be critical to mitigate the burden of influenza and COVID-19 in nursing homes.

"It's Not a Sprint, It's a Marathon": Stages of Managing a Nursing Home Throughout the Pandemic

OBJECTIVES

To qualitatively examine the impact of COVID-19 on nursing homes over the course of the pandemic from the perspective of nursing home administrators.

DESIGN

In-depth, semi-structured interviews with nursing home administrators, repeated 3 months apart for a total of 4 each from July 2020 through December 2021.

SETTINGS AND PARTICIPANTS

Administrators from a total of 40 nursing homes from 8 health care markets across the United States.

METHODS

Interviews were conducted virtually or via phone. The research team identified overarching themes using applied thematic analysis, and iteratively coded transcribed interviews.

RESULTS

Nursing home administrators across the United States reported challenges of managing nursing homes during a pandemic. We found their experiences could generally be categorized into 4 stages, not necessarily coinciding with surge levels of the virus. The initial stage was characterized by fear and confusion. The second stage, by a "new normal," a term administrators used to report feeling better prepared for an outbreak and how residents, staff, and families began to adjust to life with COVID. Administrators started using the phrase "a light at the end of the tunnel" to describe the third stage, characterized by the hope associated with the availability of vaccinations. The fourth stage was marked by "caregiver fatigue" as nursing homes experienced numerous breakthrough cases. Some challenges, like staffing issues and uncertainty about the future, were reported throughout the pandemic, as was a continued mission to keep residents safe.

CONCLUSIONS AND IMPLICATIONS

As the ability of nursing homes to provide safe, effective care faces unprecedented and continued challenges, the insights reported here from longitudinal perspectives of nursing home administrators may help policy makers develop solutions to encourage high-quality care. Knowing how the needs for resources and support vary across the progression of these stages has the potential to be helpful in addressing these challenges.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia

INTRODUCTION

Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD.

METHODS

Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month.

RESULTS

For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates.

DISCUSSION

APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD.

HIGHLIGHTS

For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

Analysis of the First Round of Public Comments for the National Coverage Determination for Monoclonal Antibodies in the Treatment of Alzheimer's Disease

Following the Food and Drug Administration's (FDA) controversial approval of aducanumab for the treatment of Alzheimer's disease, the Centers of Medicare & Medicaid Services (CMS) used its National Coverage Determination process to determine its coverage for Medicare beneficiaries. A public comment period was available for 30 days between July 12, 2021 and August 11, 2021. This study analyzed the 132 comments submitted in the first public comment period. The comments were downloaded from CMS' publicly-available website and analyzed to identify key themes across stakeholders. Three major themes were identified. Those supporting CMS approving aducanumab argued FDA's approval was appropriate and the final decision for treatment should be left to patients and their doctors. Those against or uncertain of CMS approving aducanumab stated concerns about its clinical benefits, risks, burdens, and costs; many of these stakeholders instead argued CMS institute Coverage with Evidence Development. Lastly, regardless of perspective, stakeholders encouraged CMS to cover diagnostic tools to support Alzheimer's disease research and treatments. Our analysis identifies key themes and policy implications of CMS' decision, including acknowledgment of comments and subsequent changes to CMS' determination, highlighting the value of public comments as a resource to understand stakeholder perspectives on policy decisions.

Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic

Importance

Staffing shortages have been widely reported in US nursing homes during the COVID-19 pandemic, but traditional quantitative research analyses have found mixed evidence of staffing shortfalls.

Objective

To examine whether nursing home administrator perspectives can provide context for conflicting aggregate staffing reports in US nursing homes during the COVID-19 pandemic.

Design, Setting, and Participants

In a qualitative study, convergent mixed-methods analysis integrating qualitative and quantitative data sets was used. Semistructured qualitative interviews were conducted between July 14, 2020, and December 16, 2021. Publicly available national Payroll Based Journal data were retrieved from January 1, 2020, to September 30, 2022, on 40 US nursing homes in 8 health care markets that varied by region and nursing home use patterns. Staffing and resident measures were derived from Payroll Based Journal data and compared with national trends for 15 436 US nursing homes. Nursing home administrators were recruited for interviews. Of the 40 administrators who consented to participate, 4 were lost to follow-up.

Exposure

Four repeated, semistructured qualitative interviews with participants were conducted. Interview questions focused on the changes noted during the COVID-19 pandemic in nursing homes.

Main Outcomes and Measures

Thematic description of nursing home administrator compensatory strategies to provide context for quantitative analyses on nursing home staffing levels during the COVID-19 pandemic.

Results

A total of 156 interviews were completed with 40 nursing home administrators. Administrators reported experiencing staff shortages during the COVID-19 pandemic and using compensatory strategies, such as overtime, cross-training, staff-to-resident ratio adjustments, use of agency staff, and curtailing admissions, to maintain operations and comply with minimum staffing regulations. Payroll Based Journal data measures graphed from January 1, 2020, to September 30, 2022, supported administrator reports showing that study facilities had reductions in staff hours, increased use of agency staff, and decreased resident census. Findings were similar to national trends.

Conclusions and Relevance

In this qualitative, convergent mixed-methods study, nursing home administrators reported the major staffing strain they experienced at their facilities and the strategies they used to offset staffing shortages. Their experiences provide context to quantitative analyses on aggregate nursing home census data. The short-term compensatory measures administrators used to comply with regulations and maintain operations may be detrimental to the long-term stability of this workforce.

Feasibility of conducting qualitative research with persons living with dementia and their caregivers during a home-delivered meals pilot trial

BACKGROUND

Among older adults, food insecurity is associated with poor health status and health outcomes; people living with dementia (PLWD) are at increased risk for insecurity. Approaches to addressing food insecurity among homebound older adults include two modes of home-delivered meals: (1) meals delivered daily to participants' homes by a volunteer or paid driver who socializes with the client or (2) frozen meals that are mailed to participants' homes. Research has not examined benefits of these meals for PLWD or their caregivers nor compared the effectiveness of these two approaches in reducing food insecurity. The objective of this study was to test the processes for recruiting and engaging in qualitative research with PLWD and caregivers in an effort to understand the context, implementation, and mechanisms of impact by which relationships between meal delivery and outcomes may be achieved in preparation for a larger, follow-on study.

METHODS

This is a qualitative sub-study of a pilot, multisite, two-arm pragmatic feasibility trial comparing the effect of two modes of meal delivery on nursing home placement among 243 PLWD. In this sub-study, we tested recruitment and enrollment procedures and piloted interview guides among a subset of participants and caregivers.

RESULTS

We recruited and conducted interviews with nine PLWD and seven caregivers. In testing the informed consent process, all participants were able to consent to be interviewed, and PLWD all demonstrated capacity to consent. We successfully used a cognitive screener to obtain scores of cognitive impairment for PLWD and observed scores indicating a broad range of function. Our interview guides successfully resulted in information about the context, implementation, and mechanisms of impact for meal delivery during the pilot.

CONCLUSIONS

In addition to establishing feasibility for the future trial, the substantive findings identified through the qualitative interviews provide an initial understanding of the contextual factors for meal delivery and the potential mechanisms of impact across meal delivery types that warrant further examination in a full-scale trial. Findings from our study provide crucial pilot data to support a follow-on trial to understand how to address food insecurity among PLWD.

NAME OF THE REGISTRY

ClinicalTrials.gov TRIAL REGISTRATION: NCT04850781 DATE OF REGISTRATION: April 20, 2021, retrospectively registered https://clinicaltrials.gov/ct2/show/NCT04850781.

"I know that my role is going to change": a mixed-methods study of the relationship between amyloid-β PET scan results and caregiver burden

BACKGROUND

Caregiver burden consists of disease specific and perceived stressors, respectively referred to as objective and subjective indicators of burden, and is associated with negative outcomes. Previous research has found that care partners to persons living with cognitive impairment and elevated levels of amyloid-β, as measured by a positron emission tomography (PET) scan, may experience caregiver burden.

AIMS

To elucidate the relationship between amyloid scan results and subjective and objective indicators of burden.

METHODS

A parallel mixed-methods design using survey data from 1338 care partners to persons with mild cognitive impairment (MCI) and dementia who received an amyloid scan from the CARE-IDEAS study; and semi-structured interviews with a subsample of 62 care partners. Logistic regression models were used to investigate objective factors associated with caregiver burden. A thematic analysis of semi-structured interviews was used to investigate subjective indicators by exploring care partners' perceptions of their role following an amyloid scan.

RESULTS

Elevated amyloid was not associated with burden. However, the scan result influenced participants perceptions of their caregiving role and coping strategies. Care partners to persons with elevated amyloid expected increasing responsibility, whereas partners to persons without elevated amyloid and mild cognitive impairment did not anticipate changes to their role. Care partners to persons with elevated amyloid reported using knowledge gained from the scan to develop coping strategies. All care partners described needing practical and emotional support.

CONCLUSIONS

Amyloid scans can influence subjective indicators of burden and present the opportunity to identify and address care partners' support needs.

Perspectives of Nursing Home Administrators across the United States During the COVID‐19 Pandemic

OBJECTIVE

To characterize the experiences of nursing home administrators as they manage facilities across the United States during the COVID-19 pandemic.

DATA SOURCES AND STUDY SETTING

We conducted 156 interviews, consisting of four repeated interviews with administrators from 40 nursing homes in eight health care markets across the country from July 2020 through December 2021.

STUDY DESIGN

We subjected the interview transcripts to a rigorous qualitative analysis to identify overarching themes using a modified grounded theory approach to applied thematic analysis.

DATA COLLECTION METHODS

In-depth, semi-structured qualitative interviews were conducted virtually or by phone, and audio-recorded, with participants' consent. Audio recordings were transcribed.

PRINCIPAL FINDINGS

Interviews with nursing home administrators revealed a number of important cross-cutting themes. In interviewing each facility's administrator four times over the course of the pandemic, we heard perspectives regarding the stages of the pandemic, and how they varied by the facility and changed over time. We also heard how policies implemented by federal, state, and local governments to respond to COVID-19 were frequently changing, confusing, and conflicting. Administrators described the effect of COVID-19 and efforts to mitigate it on residents, including how restrictions on activities, communal dining, and visitation resulted in cognitive decline, depression, and weight loss. Administrators also discussed the impact of COVID-19 on staff and staffing levels, reporting widespread challenges in keeping facilities staffed as well as strategies used to hire and retain staff. Administrators described concerns for the sustainability of the nursing home industry resulting from the substantial costs and pressures associated with responding to COVID-19, the reductions in revenue, and the negative impact of how nursing homes appeared in the media.

CONCLUSIONS

Findings from our research reflect nursing home administrator perspectives regarding challenges operating during COVID-19 and have substantial implications for policy and practice.

Advance directives among cognitively impaired persons who had an amyloid PET scan and their care partners: a mixed-methods study

BACKGROUND

Little research exists on the role of β-amyloid PET scans as part of Alzheimer's diagnostic tests and documentation of end-of-life preferences for persons with cognitive impairment. The study objectives were to examine the association of amyloid PET scan results (elevated vs. not elevated amyloid levels) and diagnostic category (mild cognitive impairment vs. dementia) with the likelihood of having an advance directive (reported a median of 4.5 months post-scan); to explore perceptions of PET scan results and their influence on planning for the future among persons with cognitive impairment and their care partners.

METHODS

Sequential, explanatory mixed-methods design using data from dyads in the CARE-IDEAS study: advance directives as a factor of diagnostic category and scan result using multivariable logistic regression models; thematic analysis of semi-structured interviews with persons with cognitive impairment and care partners to explore how scan results influenced documentation of future healthcare preferences. Participants included 1784 persons with cognitive impairment and care partners from the CARE-IDEAS study, and a subsample of 100 semi-structured telephone interviews.

RESULTS

81.6% of dyads reported an advance directive. Non-Hispanic, White participants had higher rates of advance directives. There was no significant association between having an advance directive and scan results. Qualitative analysis provided insight into perceived urgency to have advance directives, evolving healthcare preferences, and the context of completing advance directives.

CONCLUSIONS

Although amyloid PET scans prompted persons with cognitive impairment and care partners to consider progressive cognitive impairment as part of evolving healthcare preferences, we found substantial variability in the perceived urgency of documentation.

"Now at least we have something to call it": Patient and care partner experiences receiving an amyloid PET scan

BACKGROUND

The primary objective of this paper was to examine perspectives and experiences of individuals with cognitive impairment who received an amyloid PET scan and their care partners, with regard to the process, logistics, and decision-making associated with receiving an amyloid PET scan and its results.

METHODS

Structured telephone interviews were conducted with 200 randomly sampled scan recipient/care partner dyads from the CARE IDEAS study. The audio-recorded, transcribed responses were analyzed using an inductive qualitative content analytic approach.

RESULTS

Participating individuals and care partners described their experiences in seeking a diagnosis for memory issues, including decision-making and logistics involved with receiving an amyloid PET scan. Participants discussed the factors contributing to their decision to seek a diagnosis for their memory issues and their hopes and expectations in completing the scan. Participants also described the trajectory of this process, and although some described relatively straightforward trajectories, others described problems associated with identifying appropriate providers and coordinating care across numerous providers to obtain a diagnosis for their memory issues. Participants described an additional challenge of physicians attributing cognitive decline to normal aging, rather than signs of a neurodegenerative disorder.

CONCLUSIONS

Findings shed light on the barriers and delays that individuals and care partners experience in connecting with physicians and obtaining a comprehensive evaluation for cognitive problems. Results from this study have implications for physicians who provide care to older adults, and specifically highlight the need for greater care coordination and clearer communication with and systems of referral for patients.

'It's not just about the dinner; it's about everything else that we do': A qualitative study exploring how Meals on Wheels meet the needs of self-isolating adults during COVID-19

Meals on Wheels (MoWs), a service offered by local authorities in England, deliver meals to older, housebound and/or vulnerable adults, who might otherwise not be able to acquire and prepare their own meals. Research suggests that MoWs provide benefits beyond nutrition. Little is known about the actual interactions between service providers and clients, particularly during the COVID-19 pandemic. The aim of this small-scale, formative study was to explore MoWs service providers' experiences and their perceptions around the benefits and challenges faced by the service, and understand how these experiences changed during the first UK national lockdown. Semi-structured interviews were conducted in September 2020 with 18 service providers of MoWs (drivers who deliver the meals, service coordinators and managers) in two local authorities in England, and analysed thematically. Participants indicated that benefits of the service encompassed those to clients (e.g. welfare checks, encouraging independence and identifying and addressing isolation and loneliness), employees (e.g. sense of pride, rewarding relationships with clients) and the wider community (e.g. reducing pressures on families), and described MoWs as the 'fourth emergency service' (e.g. being the first responders to emergency situations). Participants identified several challenges faced by the MoWs service, including organisational challenges (e.g. funding cuts and closures, lack of appropriate publicity to raise awareness of the service) and restrictions on time spent with clients. The pandemic and lockdown resulted in increased demand on resources, concerns about client and staff wellbeing and uncertainty about how the service will cope if lockdowns continue. These findings provide important insights regarding the wide benefits of MoWs and the challenges the service faces, which can be used as the formative research base to guide future interventions and policies to protect vulnerable adults, not only during the COVID-19 pandemic, but beyond.

Findings from Talking Tech: A Technology Training Pilot Intervention to Reduce Loneliness and Social Isolation among Homebound Older Adults

Background and Objectives

Social isolation and loneliness are common among older adults and associated with negative health outcomes including cognitive decline, depression, suicide ideation, and mortality. Information and communication technology interventions are often used to combat loneliness and social isolation; however, homebound older adults face barriers to access. This study reports findings from a novel pilot intervention, called Talking Tech, designed to reduce loneliness and social isolation in homebound older adults by providing one-on-one, in-home technology training, a tablet, and the internet, to promote digital literacy and participation in a virtual senior center.

Research Design and Methods

Twenty-one homebound older adults participated in this 14-week, volunteer-delivered program. We used qualitative interviews with participants, volunteers, and program staff, weekly progress reports from volunteers, and quantitative pre- and postintervention surveys with participants to examine experiences and to evaluate the impact of the intervention on loneliness and social isolation. Qualitative data were analyzed using content analysis and pre- and postintervention survey data were compared.

Results

Participants reported increased technological literacy and use, increased access to online activities, and improved facilitation of social connections to existing and new networks. Additionally, during interviews, many participants reported that participating in Talking Tech alleviated their loneliness. While not statistically significant, our quantitative analysis revealed trends toward decreased participant feelings of loneliness and increased technology use. Additionally, intervention adoption and retention were high, with only one participant withdrawing from the intervention.

Discussion and Implications

This evaluation of the novel Talking Tech pilot intervention provides critical insights into strategies to reduce loneliness and isolation for older adults, with implications for future research, policy, and practice. Findings demonstrate that individualized technology training may be an acceptable way to improve well-being for homebound older adults.

How Medicare Advantage plans use data for supplemental benefits decision-making

OBJECTIVES

Health care payers are increasingly experimenting with interventions to address social risk factors. With enactment of the 2018 Bipartisan Budget Act, Medicare Advantage (MA) plans have new opportunities to offer supplemental benefits that are not "primarily health-related." This article presents findings from interviews conducted with executives from MA plans regarding plan decision-making processes related to new social risk factor benefits.

STUDY DESIGN

Semistructured qualitative interviews with MA plan leadership.

METHODS

A total of 63 plan representatives from 29 unique MA plans were interviewed about the rationale for social risk-related interventions and how data are used to inform benefits expansion decisions. This paper combines qualitative interview data from 2 separate studies with similar target groups and interview guides. Interview transcripts were qualitatively analyzed to examine underlying themes.

RESULTS

Three main themes emerged: (1) Plans use multiple data sources to determine how to target benefits; (2) evidence gaps hinder decision-making to expand or offer new supplemental benefits; and (3) in the absence of sufficient evidence, some plans have their own research and quality improvement processes to maximize effectiveness.

CONCLUSIONS

Findings provide insights about opportunities and challenges that MA plans face in making decisions related to supplemental benefits designed to address members' social risk factors. Barriers include collecting, generating, and analyzing data critical to informing investments. Results highlight the need to ensure interoperability of new and existing data sources, foster shared learning opportunities, and narrow evidence gaps about specific social care interventions to inform the design and implementation of effective supplemental benefits.

A Technology Training Program to Alleviate Social Isolation and Loneliness Among Homebound Older Adults: A Community Case Study

Despite substantial evidence of the negative health consequences of social isolation and loneliness and the outsized impact on older adults, evidence on which interventions are most effective in alleviating social isolation and loneliness is inconclusive. Further complicating the translation of evidence into practice is the lack of studies assessing implementation and scalability considerations for socialization programs delivered by community-based organizations (CBOs). Our primary objective was to describe the implementation barriers, facilitators, and lessons learned from an information and communication technology (ICT) training program aimed at reducing social isolation and loneliness for homebound older adults in a home-delivered meals program. Participants received in-home, one-on-one ICT training lessons delivered by volunteers over a 14-week period with the goal of increasing social technology use. To assess implementation facilitators and barriers, 23 interviews were conducted with program staff (n = 2), volunteers (n = 3), and participants (n = 18). Transcripts were analyzed using thematic analysis. Aspects that facilitated implementation included the organization's existing relationship with clientele, an established infrastructure to deliver community-based interventions, alignment of intervention goals with broader organizational aims, and funding to support dedicated program staff. Challenges to implementation included significant program staff time and resources, coordinating data sharing efforts across multiple project partners, participant and volunteer recruitment, and interruptions due to COVID-19. Implications of these facilitators and barriers for scalability of community-based ICT training interventions for older adults are described. Lessons learned include identifying successful participant and volunteer recruitment strategies based on organizational capacity and existing recruitment avenues; using a targeted approach to identify potential participants; incorporating flexibility into intervention design when working with the homebound older adult population; and monitoring the participant-volunteer relationship through volunteer-completed reports to mitigate issues. Findings from this formative evaluation provide insight on strategies CBOs can employ to overcome challenges associated with implementing technology training programs to reduce social isolation and loneliness for older adults, and thus improve overall well-being for homebound older adults. Recommendations can be integrated into program design to facilitate implementation of ICT programs in the community setting.

The Lived Experiences of Adults with Multiple Sclerosis

Multiple sclerosis (MS), a chronic, often disabling, nervous system disease, affects over 2.3 million people worldwide. This research examined the lived experiences of 46 community-dwelling adults with MS. We conducted five focus groups that covered topics such as diagnosis, decision-making regarding MS treatment, learning about and paying for assistance, and unmet needs. Focus group transcripts were qualitatively analyzed to identify overarching themes. Participants described how MS affects both current and future physical and financial security, how they often feel unheard or misunderstood by loved ones and healthcare providers, and how MS support organizations provide a vital collaborative and compassionate environment. Our findings reflect the importance of MS support organizations, and the incorporation of social workers in MS care teams, as they can foster communication and empathy between parties, provide psycho- social treatment, and link patients to needed services.

Health Care and Community-Based Organization Partnerships to Address Social Needs: Medicare Advantage Plan Representatives' Perspectives

Payers and providers are increasingly being held accountable for the overall health of their populations and may choose to partner with community-based organizations (CBOs) to address members' social needs. This study examines the opportunities and challenges that health care entities, using Medicare Advantage (MA) plans as an example, encounter when forming these relationships. We conducted interviews with 38 representatives of 17 MA organizations, representing 65% of MA members nationally. Transcripts were qualitatively analyzed to understand overarching themes. Participants described qualities they look for in community partners, including an alignment of organizational missions and evidence of improved outcomes. Participants also described challenges in working with CBOs, including needing an evidence base for CBOs' services and an absence of organizational infrastructure. Results demonstrate areas where CBOs may target their efforts to appeal to payers and providers and reveal a need for health care entities to assist CBOs in acquiring skills necessary for partnerships.

Readmission Reduction Strategies for Patients Discharged to Skilled Nursing Facilities: A Case Study From 2 Hospital Systems in 1 City

BACKGROUND

Some hospitals seek integration with skilled nursing facilities (SNFs) to reduce readmissions while others focus more on patients discharged home.

PURPOSE

Our objective was to understand different approaches for readmission reduction for patients discharged to SNFs based on contrasting strategies from 2 competing hospital systems.

METHODS

Employing a case study methodology, we compared 1 hospital system that integrated with SNFs to a competing system that did not. We compared interview data from clinical and administrative staff and publicly reported rehospitalization rate changes from the 2 systems.

RESULTS

Analysis of integrating hospital system interviews noted providing patients detailed discharge information and educating SNF staff regarding care protocols. Integrated hospital system all-cause readmission rates declined by nearly 1 percentage point more than the nonintegrated hospital system (coefficient, -0.008; 95% confidence interval, -0.003 to -0.012) between 2014 and 2017.

CONCLUSION

As hospitals explore care transition improvements to SNFs, developing more embedded relationships highlights one approach to improve value.

Medicare Plans' Adoption of Special Supplemental Benefits for the Chronically Ill for Enrollees With Social Needs

This cross-sectional study assesses the extent to which Medicare plans have offered Special Supplemental Benefits for the Chronically Ill for enrollees with social needs.

Medicare Advantage plan representatives' perspectives on Pay for Success

OBJECTIVES

To understand how Medicare Advantage (MA) plan representatives perceive the alternative financing model Pay for Success (PFS) and its potential to address members' social risk factors.

STUDY DESIGN

Semistructured qualitative interviews designed to understand plan representatives' priorities regarding addressing nonmedical needs of their members, awareness of and experiences with PFS, and thoughts about implementing PFS as a method to address members' nonmedical needs.

METHODS

Interviews with 38 upper-management representatives from 17 MA plans, which represent 65% of MA beneficiaries nationally, were conducted from July to November 2018. Plans varied in geographic coverage, star rating, and enrollment. Transcripts were qualitatively analyzed to understand overarching themes and patterns of responses.

RESULTS

MA plan representatives were largely unfamiliar with PFS and were interested in learning more about how it could address members' social needs. When probed about specific requirements of PFS, responses varied: Some reported willingness to share data with project partners and be reviewed by independent evaluators; others expressed their preference to keep data and performance analysis internal to the organization. Although most representatives prioritized innovation, some were more risk averse and preferred to use traditional methods to deliver new services.

CONCLUSIONS

MA plan representatives were unfamiliar with PFS, but most expressed interest in it as an alternative model for funding initiatives to address members' social needs. Education of MA representatives about PFS as an alternative payment model for innovative programming is warranted. However, further guidance from CMS is needed to assuage the concerns raised by these representatives.

Perspectives of Medicare Advantage Plan Representatives on Addressing Social Determinants of Health in Response to the CHRONIC Care Act

Importance

The passage of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act in 2018 allows Medicare Advantage (MA) plans, which enroll more than one-third of Medicare beneficiaries, greater flexibility to address members' social determinants of health (SDOH) through supplemental benefits.

Objective

To understand MA plan representatives' perspectives on the importance of addressing members' SDOH and their responses to the passage of the CHRONIC Care Act.

Design, Setting, and Participants

This semistructured qualitative interview study conducted via telephone from July 6, 2018, to November 7, 2018, included participants from 17 MA plans that collectively enrolled more than 13 million MA members (>65% of the total MA market). Data analysis was conducted from September 18, 2018, to December 13, 2018.

Main Outcomes and Measures

Audio-recorded interviews were transcribed and then analyzed using a modified content analysis approach to identify major themes and subthemes.

Results

Thirty-eight participants representing 17 MA plans varying in region, star rating, and size were interviewed. Analysis of interviews revealed 3 key themes. The first theme was that participants increasingly recognize the value of addressing members' SDOH. The second theme was that participants had different perspectives on whether MA plans should directly address SDOH and how to do so. While some reported that they were taking advantage of the increased flexibility provided by the CHRONIC Care Act to design new benefits or partner with community-based organizations, others indicated that it was outside of their purview to directly address members' SDOH. The third theme was that participants described complex decision-making around how to provide supplemental benefits, including a need for evidence, return on investment, strong community partnerships, and guidance from the US Centers for Medicare & Medicaid Services.

Conclusions and Relevance

These findings suggest that the changes in MA plans' benefit packages in response to the CHRONIC Care Act and their efforts to address SDOH will vary. Therefore, it is likely that MA enrollees will be differentially affected by the implementation of the CHRONIC Care Act.

Early Adoption of New Supplemental Benefits by Medicare Advantage Plans

Following CMS’ 2018 expansion of supplemental benefits available to HMO and PPO Medicare Advantage enrollees, this study assesses enrollee adoption by type of benefit (eg, caregiver support, in-home personal care, palliative nursing, and social work) and specific plan characteristics in the first year.

Quality Management Strategies in Medicaid Managed Care: Perspectives From Medicaid, Plans, and Providers

Medicaid managed care allows Medicaid beneficiaries to receive services through contractual relationships between managed care organizations and state Medicaid offices. Medicaid offices monitor quality of care, and many states encourage or require plans to adopt quality management practices. This research examines quality management in Medicaid managed care from the perspectives of Medicaid officials, managed care plan representatives, and providers through 25 qualitative interviews in one Northeastern state. Plan representatives described quality management efforts as robust and discussed strategies targeting providers and beneficiaries. Medicaid officials indicated motivations for plans to be responsible for quality management. Providers were unaware of plan efforts or reported them to be counterproductive since performance data were thought to be inaccurate or limited, and modest incentive programs presented excessive administrative burden. Providers' general skepticism about managed care plans' quality improvement efforts may hinder their effectiveness, cause frustration, and lead to administrative burden that may harm care quality.

Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility

OBJECTIVE

This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff.

DESIGN

We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients' experiences, hospital-SNF communication, and the presence of programs to improve the transition process.

PARTICIPANTS

Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets.

APPROACH

Interviews were qualitatively analyzed to identify overarching themes.

KEY RESULTS

Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown.

CONCLUSIONS

Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed.

"It's Not Just a Simple Meal. It's So Much More": Interactions Between Meals on Wheels Clients and Drivers

Background and Objectives: Meals on Wheels (MOW) programs provide home-delivered meals to over 1.5 million older adults; yet, very little is known about the drivers who make meal deliveries possible. Specifically, we do not have clear insight into their interaction with clients or the benefits that they may receive through their service. The objective of this article is to describe the characteristics of MOW drivers, the interactions among drivers and clients, and the benefits of the program to both. Research Design and Method: This qualitative research study reports on interviews with 84 MOW staff (leadership, case managers/client assessors, volunteer coordinators) and drivers at six geographically and operationally distinct programs across the United States. Results: Qualitative analysis of the interviews with MOW staff and drivers revealed the following key themes: (a) clients have multiple vulnerabilities; (b) clients appear to derive social, as well as nutritional benefit from receiving meals; (c) drivers report they provide additional support to their clients beyond delivering the meal; (d) social bonds between drivers and clients were reported to strengthen over time; (e) drivers claim that they, too, derive validation and personal benefit through their meal delivery. Discussion and Implications: This research highlights the significant contributions that meal delivery drivers made in the lives of MOW clients beyond the actual meal itself. This research also spotlights the perceived benefits experienced by the drivers and points to the importance of conducting further research to determine the effects of meal delivery on client and drivers' outcomes, more broadly.

Medicare Advantage control of postacute costs: perspectives from stakeholders

OBJECTIVES

Medicare Advantage (MA) plans have strong incentives to control costs, including postacute spending; however, to our knowledge, no research has examined the methods that MA plans use to control or reduce postacute costs. This study aimed to understand such MA plan efforts and the possible unintended consequences.

STUDY DESIGN

A multiple case study method was used.

METHODS

We conducted 154 interviews with administrative and clinical staff working in 10 MA plans, 16 hospitals, and 25 skilled nursing facilities (SNFs) in 8 geographically diverse markets across the United States.

RESULTS

Participants discussed how MA plans attempted to reduce postacute care spending by controlling the SNF to which patients are discharged and SNF length of stay (LOS). Plans typically influenced SNF selection by providing patients with a list of facilities in which their care would be covered. To influence LOS, MA plans most commonly authorized patient stays in SNFs for a certain number of days and required that SNFs adhere to this limitation, but they did not provide guidance or assistance in ensuring that the LOS goals were met. Hospital and SNF responses to the largely authorization-based system were frequently negative, and participants expressed concerns about potential unintended consequences.

CONCLUSIONS

In their interactions with hospitals and SNFs, MA plans attempted to influence the choice of SNF and LOS to control postacute spending. However, exerting too much influence over hospitals and SNFs, as these results seem to indicate, may have the negative consequences of delayed hospital discharge and SNFs' avoidance of burdensome plans.

Qualitative perspectives of primary care providers who treat Medicaid managed care patients

Background

Declining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis.

Methods

We conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes.

Results

Providers expressed challenges effectively meeting their patients’ needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice.

Conclusions

Underinvestment in primary care in Medicaid may detract from providers’ professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.

Hospital-Skilled Nursing Facility Collaboration: A Mixed-Methods Approach to Understanding the Effect of Linkage Strategies

OBJECTIVE

To characterize the nature and degree of hospitals' efforts to collaborate with skilled nursing facilities (SNFs) and associated patient outcomes.

DATA SOURCES/STUDY SETTING

Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNFs in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015.

STUDY DESIGN/DATA COLLECTION

Semi-structured interviews with hospital and SNF staff were coded and used to classify hospitals' collaboration efforts with SNFs into high versus low collaboration hospitals, and risk-adjusted, claims-based hospital readmission rates from SNF were compared.

PRINCIPAL FINDINGS

Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNFs. High collaboration hospitals were more likely to send patients to SNFs (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNFs, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals.

CONCLUSIONS

Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes.

The Impact of Medicaid Managed Care Plan Type on Continuous Medicaid Enrollment: A Natural Experiment

OBJECTIVE

To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage.

DATA SOURCES

2011-2016 Medicaid claims from a Northeastern state.

STUDY DESIGN

Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis.

DATA COLLECTION

We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011.

PRINCIPAL FINDINGS

Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid.

CONCLUSIONS

Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.

Patients Are Not Given Quality-Of-Care Data About Skilled Nursing Facilities When Discharged From Hospitals

Hospitals are now being held at least partly accountable for Medicare patients' care after discharge, as a result of regulations and incentives imposed by the Affordable Care Act. However, little is known about how patients select a postacute care facility. We used a multiple case study approach to explore both how patients requiring postacute care decide which skilled nursing facility to select and the role of hospital staff members in this decision. We interviewed 138 staff members of sixteen hospitals and twenty-five skilled nursing facilities and 98 patients in fourteen of the skilled nursing facilities. Most patients described receiving only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities' quality with patients because they believed that patient choice regulations precluded them from doing so. Consequently, patients' choices were rarely based on readily available quality data. Proposed changes to the Medicare conditions of participation for hospitals that pertain to discharge planning could rectify this problem. In addition, less strict interpretations of choice requirements would give hospitals flexibility in the discharge planning process and allow them to refer patients to higher-quality facilities.

Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay

OBJECTIVE

To identify the challenges that reductions in length of stay (LOS) pose for skilled nursing facilities (SNFs) and their postacute care (PAC) patients.

DATA SOURCES/SETTING

Seventy interviews with staff in 25 SNFs in eight U.S. cities, LOS data for patients in those SNFs.

STUDY DESIGN

Data were qualitatively analyzed, and key themes were identified. Interview data from SNFs with and without reductions in median risk-adjusted LOS were compared and contrasted.

DATA COLLECTION/EXTRACTION METHODS

We conducted 70 semistructured interviews. LOS data were derived from minimum dataset (MDS) admission records available for all patients in all U.S. SNFs from 2012 to 2014.

PRINCIPAL FINDINGS

Challenges reported regardless of reductions in LOS included frequent and more complicated re-authorization processes, patients becoming responsible for costs, and discharging patients whom staff felt were unsafe at home. Challenges related to reduced LOS included SNFs being pressured to discharge patients within certain time limits. Some SNFs reported instituting programs and processes for following up with patients after discharge. These programs helped alleviate concerns about patients, but they resulted in nonreimbursable costs for facilities.

CONCLUSIONS

The push for shorter LOS has resulted in unexpected challenges and costs for SNFs and possible unintended consequences for PAC patients.

Selecting a Skilled Nursing Facility for Postacute Care: Individual and Family Perspectives

OBJECTIVES

To describe individuals' experiences during the hospital discharge planning and skilled nursing facility (SNF) selection process.

DESIGN

Semistructured interviews focusing on discharge planning and nursing facility selection, including how facilities were chosen, who was involved, and what factors were important in decision-making.

SETTING

14 SNFs in five cities across the United States.

PARTICIPANTS

Newly admitted, previously community-dwelling SNF residents (N = 98) and their family members.

MEASUREMENT

Semistructured interviews were qualitatively coded to identify underlying themes.

RESULTS

Most respondents reported receiving only a list of SNF names and addresses from discharge planners and that hospital staff were minimally involved. Proximity to home and prior experience with the facility most often influenced choice of SNF. Most respondents reported being satisfied with their placement, although many stated that they would have been willing to travel further to another SNF were it recommended. Many reported feeling rushed and unprepared, stating that they did not know where or how to get help.

CONCLUSION

SNF placement is a stressful transition, occurring when people are physically vulnerable and with limited guidance from discharge planners. Therefore, most people select a facility based on its location, perhaps because they are provided with no other information. Given Centers for Medicare and Medicaid Services' proposed changes to the discharge planning process, this research highlights the value of providing people and family caregivers with quality data and assistance in interpreting it.

Trends in state regulation of nurse practitioners and physician assistants, 2001 to 2010

Nurse practitioners and physician assistants can alleviate some of the primary care shortage facing the United States, but their scope-of-practice is limited by state regulation. This study reports both cross-sectional and longitudinal trends in state scope-of-practice regulations for nurse practitioners and physician assistants over a 10-year period. Regulations from 2001 to 2010 were compiled and described with respect to entry-to-practice standards, physician involvement in treatment/diagnosis, prescriptive authority, and controlled substances. Findings indicate that most states loosened regulations, granting greater autonomy to nurse practitioners and physician assistants, particularly with respect to prescriptive authority and physician involvement in treatment and diagnosis. Many states also increased barriers to entry, requiring high levels of education before entering practice. Knowledge of state trends in nurse practitioner and physician assistant regulation should inform current efforts to standardize scope-of-practice nationally.

The Big Five Personality Factors as Predictors of Driving Status in Older Adults

Objective: Although factors including cognitive and health status have been associated with driving cessation in older adults, the role of psychosocial variables is not well studied. Previous research on young adult drivers has suggested that personality may be related to driving behavior, but this study is among the first to explore the relationship between driving status and the Big Five Model of personality for older adults. Method: Data are from the Health and Retirement Study (2008 wave, n = 4,028). Descriptive, bivariate, and multiple logistic regression analyses were conducted. Results: Neuroticism (β = −0.4511, p < .001) and agreeableness (β = −0.5058, p < .001) were associated with decreased likelihood of driving; extraversion (β = 0.4588, p < .001), openness (β = 0.5903, p < .001), and conscientiousness (β = 0.4077, p < .001) were associated with increased likelihood of driving, although results were partially mediated by including known risk factors. People who limited their driving to nearby locations were the most different from those who no longer drove. Discussion: Personality adds a unique contribution to the prediction of late-life driving status.