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Manis DR, Kirkwood D, Li W, Webber C, Fisher S, Tanuseputro P, Watt JA, Backman C, Stall NM, Costa AP. Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study. J Am Med Dir Assoc 2024; 25:105270. [PMID: 39313036 DOI: 10.1016/j.jamda.2024.105270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 09/25/2024]
Abstract
OBJECTIVE To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services. DESIGN Nested case-control study. SETTING AND PARTICIPANTS Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December 31, 2019. New residents of assisted living were matched on age, sex, and initiation date of home care (± 7 days) to community-dwelling home care recipients in a 1:4 ratio. METHODS Clinical and functional status, health service use, sociodemographic variables, and community-level characteristics were examined; conditional logistic regression was used to model associations with a transition to an assisted living facility. RESULTS There were 2427 new residents of assisted living who were matched to 9708 home care recipients [mean (SD) age 85.5 (6.02) years, 72% female]. Most of the new residents were concentrated in urban communities and communities with higher income quintiles. New residents had an increased rate of physician-diagnosed dementia [adjusted hazard ratio (aHR), 1.28; 95% CI, 1.14-1.43], mood disorders (aHR, 1.17; 95% CI, 1.05-1.29), and cardiac arrhythmias (aHR, 1.19; 95% CI, 1.07-1.32). They also had higher rates of mild cognitive impairment (aHR, 1.43; 95% CI, 1.24-1.66), 2 or more falls (aHR, 1.29; 95% CI, 1.11-1.51), participation in activities of long-standing interest in the past 7 days (aHR, 1.29; 95% CI, 1.11-1.50), and a lower rate of a spouse or partner unpaid caregiver vs a child (aHR, 0.66; 95% CI, 0.56-0.79). CONCLUSIONS AND IMPLICATIONS New residents of assisted living were mostly women, were cognitively impaired, had clinical comorbidities that could increase their risk of injuries, and had caregivers who were their children. These findings stress the importance of upscaling memory and dementia care in assisted living to address the needs of this population.
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Affiliation(s)
- Derek R Manis
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; ICES, Toronto, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada.
| | | | - Wenshan Li
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Colleen Webber
- ICES, Toronto, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Stacey Fisher
- ICES, Toronto, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada
| | - Jennifer A Watt
- ICES, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Chantal Backman
- Bruyère Research Institute, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Nathan M Stall
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of General Internal Medicine and Geriatrics, Sinai Health and the University Health Network, Toronto, Canada; Women's Age Lab, Women's College Hospital, Toronto, ON, Canada
| | - Andrew P Costa
- ICES, Toronto, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Schlegel Research Institute for Aging, Waterloo, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada
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Reckrey JM, McKendrick K, Morrison RS, Osakwe ZT, Ornstein KA, Aldridge M. Variation in Hospice Aide Care by Residential Setting. J Palliat Med 2024; 27:1018-1025. [PMID: 38647702 DOI: 10.1089/jpm.2023.0585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Background: Hospice care frequently includes hands-on care from hospice aides, but the need for hospice aide care may vary in residential settings (e.g., assisted livings and nursing homes). Objectives: The objective of this study is to compare hospice aide use and factors associated with use across residential settings. Design: This longitudinal cohort study used data from Medicare beneficiaries in the United States enrolled in the Medicare Current Beneficiary Survey (MCBS) who died between 2010 and 2019 and had hospice claims and available residential setting data in MCBS (n = 1,915). Analysis: Decedent hospice aide use was compared by residential settings; multivariable models controlling for sociodemographic, clinical/functional, and hospice characteristics examined factors associated with hospice aide care in different residential settings. Results: Hospice aide visits were least common in the community setting (64.4% vs. 76.6% vs. 72.6% with any hospice aide visits in community, assisted living, and nursing home, respectively, p = 0.001). In adjusted models, factors associated with hospice aide visits did not significantly differ by residential settings. Conclusions: Despite staff providing hands-on support in assisted livings and nursing homes, hospice aide visits were more common in residential as opposed to community settings, and factors associated with hospice aide visits were similar among settings. To maximize the potentially positive impact of hospice aides on overall care, additional work is needed to understand when hospice aides are used and how hospice aides collaborate with families and care teams. This will help to ensure that hospice care is appropriately tailored to individual care needs in all residential settings.
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Affiliation(s)
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zainab Toteh Osakwe
- Adelphi University College of Nursing and Public Health, New York, New York, USA
| | | | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Wang X(J, Cornell PY, Belanger E, Thomas KS. Do end-of-life outcomes differ by assisted living memory-care designation? J Am Geriatr Soc 2024; 72:2491-2499. [PMID: 38567799 PMCID: PMC11323181 DOI: 10.1111/jgs.18899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/12/2024] [Accepted: 03/04/2024] [Indexed: 04/24/2024]
Abstract
BACKGROUND Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer's disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate aging/dying in place for this population. The objective of this paper is to examine if end-of-life outcomes (i.e., mortality, hospice use, and number of days receiving hospice in the last month of life) differ between residents with ADRD who moved to memory-care RC/AL, compared with residents with ADRD who moved to RC/AL without memory care (general RC/AL). METHODS Prospective cohort of 15,152 fee-for-service Medicare beneficiaries with ADRD who moved to large RC/AL (> = 25 beds) between 2016 and 2018. We used inverse probability treatment weighting to account for observable differences between memory-care and general RC/AL residents. Two-part models estimated the difference by memory care in the number of days receiving hospice care in the last months of life among RC/AL decedents. RESULTS The unadjusted mortality rates were 13.4% in general RC/AL and 15.8% in memory-care RC/AL with an adjusted difference of 1.3 percentage points higher mortality among memory-care RC/AL residents (p = 0.04). Hospice use was 8% and 10.6% among general and memory-care RC/AL residents, respectively, with an adjusted difference of 1.4 percentage points (p = 0.01) higher in memory care. Two-part models showed that decedents in memory-care RC/AL spent about 1.4 more days receiving hospice care in the last month of life (p = 0.02). CONCLUSION We find a higher mortality rate and higher rate of hospice use among memory-care RC/AL residents. These findings suggest that memory care may attract residents closer to the end of life and/or promote hospice use at the end of life.
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Affiliation(s)
- Xiao (Joyce) Wang
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Portia Y. Cornell
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Centre for the Digital Transformation of Health/Centre for Health Policy, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Victoria, Australia
| | - Emmanuelle Belanger
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kali S. Thomas
- Center for Equity in Aging, Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Thomas KS, Smith L, Gadkari G, Hua C, Cornell P. Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method. J Am Med Dir Assoc 2023; 24:1513-1517.e3. [PMID: 37268016 DOI: 10.1016/j.jamda.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/13/2023] [Accepted: 04/17/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Present an updated approach to identifying Medicare beneficiaries residing in licensed assisted living (AL) settings in the United States. DESIGN Retrospective cohort study using a national list of licensed AL settings, US Postal Service (USPS) data, and enrollment, claims, and assessment data from the Centers for Medicare and Medicaid Services. SETTING AND PARTICIPANTS A total of 403,326 beneficiaries residing in 29,905 licensed AL settings. METHODS We identified every ZIP+4 code affiliated with each AL address. We then identified all of the Medicare beneficiaries with that ZIP+4 on January 1, 2019, and excluded beneficiaries in nursing homes and hospitals on that date. We identified beneficiaries who were "definitively" and "very likely AL residents" according to the number of addresses corresponding to the ZIP+4 in the USPS data, the capacity of the AL setting, and the presence of a claim or assessment indicating services were delivered in AL. We compared beneficiaries excluded during our new capacity restriction step (ie, "possibly neighbors") to those included as being "definitively" and "very likely AL residents" using standardized mean differences. RESULTS The cohort excluded (ie, "possibly neighbors") using our new step in the identification process appears to be younger and healthier than the cohorts we include as being "definitively" and "very likely AL residents." In addition, the cohort we identified through our added step of supplementing with claims and assessment data have similar demographics to the other cohorts we include, although they appear to be in poorer health. CONCLUSIONS AND IMPLICATIONS Leveraging licensed capacity information and supplementing with claims and assessment data produce greater confidence in the ability to accurately identify AL residents using ZIP+4 codes reported in Medicare administrative data.
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Affiliation(s)
- Kali S Thomas
- Brown University School of Public Health, Providence, RI, USA; Providence VA Medical Center, Providence, RI, USA.
| | - Lindsey Smith
- Brown University School of Public Health, Providence, RI, USA
| | - Gauri Gadkari
- Brown University School of Public Health, Providence, RI, USA
| | - Cassandra Hua
- Brown University School of Public Health, Providence, RI, USA; Providence VA Medical Center, Providence, RI, USA
| | - Portia Cornell
- Brown University School of Public Health, Providence, RI, USA; Providence VA Medical Center, Providence, RI, USA
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Wang X(J, Teno JM, Rosendaal N, Smith L, Thomas KS, Dosa D, Gozalo PL, Carder P, Belanger E. State Regulations and Assisted Living Residents' Potentially Burdensome Transitions at the End of Life. J Palliat Med 2023; 26:757-767. [PMID: 36580545 PMCID: PMC10278021 DOI: 10.1089/jpm.2022.0360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/31/2022] Open
Abstract
Background: Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end-of-life care reported by bereaved family members. We examined the association between state RC/AL regulations relevant to end-of-life care delivery and the likelihood of residents experiencing potentially burdensome transitions. Methods: Retrospective cohort study combining RC/AL registries of states' regulations with Medicare claims data for residents in large RC/ALs (i.e., 25+ beds) in the United States on the 120th day before death (N = 129,153), 2017-2019. Independent variables were state RC/AL regulations relevant to end-of-life care, including third-party services, staffing, and medication management. Analyses included: (1) separate logistic regression models for each RC/AL regulation, adjusting for sociodemographic covariates; (2) separate logistic regression models with a Medicare fee-for-service (FFS) subgroup to control for comorbidities, and (3) multivariable regression analysis, including all regulations in both the overall sample and the Medicare FFS subgroup. Results: We found a lack of associations between potentially burdensome transitions and regulations regarding third-party services and staffing. There were small associations found between regulations related to medication management (i.e., requiring regular medication reviews, permitting direct care workers for injections, requiring/not requiring licensed nursing staff for injections) and potentially burdensome transitions. Conclusions: In this cross-sectional study, the associations of RC/AL regulations with potentially burdensome transitions were either small or not statistically significant, calling for more studies to explain the wide variation observed in end-of-life outcomes among RC/AL residents.
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Affiliation(s)
- Xiao (Joyce) Wang
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Joan M. Teno
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Nicole Rosendaal
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Lindsey Smith
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kali S. Thomas
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - David Dosa
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Pedro L. Gozalo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Paula Carder
- Institute on Aging, Portland State University, Portland, Oregon, USA
- School of Public Health, Oregon Health and Science University - Portland State University, Portland, Oregon, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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Guo W, Cai S, Caprio T, Schwartz L, Temkin-Greener H. End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations. J Am Med Dir Assoc 2023; 24:827-832.e3. [PMID: 36913979 PMCID: PMC10238640 DOI: 10.1016/j.jamda.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 12/19/2022] [Accepted: 02/03/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations. DESIGN Cohort study. SETTING AND PARTICIPANTS Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662). METHODS We used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics. RESULTS End-of-life care transitions were observed among 34.89% of our study sample in the last 30 days before death, and among 17.25% in the last 7 days. Higher frequency of care transitions in the last 7 days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR) = 1.08; P = .002] and direct care worker staffing (IRR = 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR = 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR = 1.15; P < .0001) and training (IRR = 0.79; P < .001) and transitions within 30 days of death. CONCLUSIONS AND IMPLICATIONS There were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30 days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.
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Affiliation(s)
- Wenhan Guo
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Thomas Caprio
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Belanger E, Rosendaal N, Wang X(J, Teno JM, Dosa DM, Gozalo PL, Carder P, Thomas KS. Association Between State Regulations Supportive of Third-party Services and Likelihood of Assisted Living Residents in the US Dying in Place. JAMA HEALTH FORUM 2022; 3:e223432. [PMID: 36206007 PMCID: PMC9547316 DOI: 10.1001/jamahealthforum.2022.3432] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Importance Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective To examine the association between state regulations and the likelihood of assisted living residents dying in place. The study hypothesis was that regulations supporting third-party services, such as hospice, increase the likelihood of assisted living residents dying in place. Design, Setting, and Participants This retrospective cohort study combined data about assisted living residences in the US from state registries with an inventory of state regulations and administrative claims data. The study participants comprised 168 526 decedents who were Medicare beneficiaries, resided in 8315 large, assisted living residences (with ≥25 beds) across 301 hospital referral regions during the last 12 months of their lives, and died between 2017 and 2019. Descriptive analyses were performed at the state level, and 3-level multilevel models were estimated to examine the association between supportive third-party regulations and dying in place in assisted living residences. The data were analyzed from September 2021 to August 2022. Exposures Supportive (vs "silent," ie, not explicitly mentioned in regulatory texts) state regulations regarding hospice care, private care aides, and home health services, as applicable to licensed/registered assisted living residences across the US. Main Outcomes and Measures Presence in assisted living residences on the date of death. Results The median (IQR) age of the 168 526 decedents included in the study was 90 (84-94) years. Of these, 110 143 (65.4%) were female and 158 491 (94.0%) were non-Hispanic White. Substantial variation in the percentage of assisted living residents dying in place was evident across states, from 18.0% (New York) to 73.7% (Utah). Supportive hospice and home health regulations were associated with a higher odds of residents dying in place (adjusted odds ratio [AOR], 1.38; 95% CI, 1.24-1.54; P < .001; and AOR, 1.21; 95% CI, 1.10-1.34; P < .001, respectively). In addition, hospice regulations remained significant in fully adjusted models (AOR, 1.46; 95% CI, 1.25-1.71). Conclusions and Relevance The findings of this cohort study suggest that a higher percentage of assisted living residents died in place in US states with regulations supportive of third-party services. In addition, assisted living residents in licensed settings with regulations supportive of hospice regulations were especially likely to die in place.
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Affiliation(s)
- Emmanuelle Belanger
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Nicole Rosendaal
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Xiao (Joyce) Wang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - David M. Dosa
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island,US Department of Veterans Affairs Medical Center, Providence, Rhode Island,The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Pedro L. Gozalo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island,US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Paula Carder
- Institute on Aging, School of Public Health, Oregon Health and Science University–Portland State University, Portland
| | - Kali S. Thomas
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island,US Department of Veterans Affairs Medical Center, Providence, Rhode Island
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Temkin-Greener H, Guo W, Hua Y, Li Y, Caprio T, Schwartz L, Cai S. End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations. Health Aff (Millwood) 2022; 41:654-662. [PMID: 35500176 DOI: 10.1377/hlthaff.2021.01677] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assisted living communities are the final home for many of their residents, most of whom are older, frail, and cognitively or functionally impaired. Yet little is known about end-of-life care in this setting. We examined associations of both death at home and home hospice care with individual characteristics, such as race or ethnicity and dual Medicare-Medicaid enrollment; community characteristics; and the stringency of state-level assisted living regulations. Of the 100,783 fee-for-service Medicare beneficiaries residing in 16,560 assisted living communities who died in 2018-19, almost 60 percent died at home, 84 percent of them with home hospice. In predicting the likelihood of death at home, dual Medicare-Medicaid enrollment was more important than race or ethnicity; in contrast, race was a stronger predictor than dual enrollment for hospice care at death. Residents were less likely to die at home or with home hospice in states with lower regulatory stringency regarding assisted living communities. These findings may help inform efforts to ensure equitable access to desired end-of-life care in this setting and suggest an important role for state-level regulation.
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Affiliation(s)
| | | | | | - Yue Li
- Yue Li, University of Rochester
| | | | - Lindsay Schwartz
- Lindsay Schwartz, American Health Care Association, Washington, D.C
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