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

Inequities in medicaid home- and community-based services waiver enrollment among people with intellectual and/or developmental disabilities: A nationwide claims-based analysis

BACKGROUND

States use Medicaid 1915(c) waiver programs to enable access to home- and community-based services for people with intellectual and/or developmental disabilities (I/DD). However, enrollment rates and potential inequities are not well documented, impeding efforts to improve care access and quality for waiver program enrollees, especially for racially minoritized beneficiaries experiencing compounded barriers to services and supports.

OBJECTIVE

To characterize year-by-year 1915(c) waiver program enrollment among Medicaid-enrolled adults with I/DD from 2016 to 2019 and to analyze population-level inequities by type of I/DD and racial/ethnic group.

METHODS

Our data source was 2016-2019 Medicaid Transformed Medicaid Statistical Information System Analytic Files Demographic and Eligibility files for beneficiaries with Down syndrome, autism, and intellectual disability. We used generalized estimating equation linear models to estimate the associations of type of I/DD and racial/ethnic group with the probability of 1915(c) waiver program enrollment and reported (1) unadjusted estimates and (2) estimates adjusted for demographics with state and year fixed effects.

RESULTS

From 2016 to 2019, across all types of I/DD and racial/ethnic groups, unadjusted 1915(c) waiver program enrollment rates ranged from 40 to 60 % nationwide. We found modest growth in 1915(c) I/DD waiver program enrollment but persistent inequities over time. Compared to beneficiaries with intellectual disabilities, beneficiaries with autism were less likely to enroll while beneficiaries with Down syndrome were more likely. While some racial/ethnic groups had higher unadjusted mean enrollment, after adjustment, racially minoritized beneficiaries were 3.66-12.0 percentage points less likely to enroll compared to white non-Hispanic beneficiaries.

CONCLUSIONS

Given extensive waiting lists for 1915(c) waiver programs, Medicaid programs should evaluate existing enrollment and authorization processes and consider alternative HCBS program authorities.

Unmet needs for long-term services and supports and associations with health outcomes

BACKGROUND

The availability of population-level data on unmet needs for long-term services and supports (LTSS) is limited at state and national levels. Data on unmet LTSS needs can improve our understanding of disparities and relationships with health outcomes.

OBJECTIVE

1) Explore differences in unmet LTSS needs by socio-demographic characteristics, including age, sex, race/ethnicity, metropolitan status, sexual orientation, and socio-economic status; and 2) Examine associations between unmet LTSS needs and health/preventative healthcare outcomes.

METHODS

We used the 2021 Behavioral Risk Factor Surveillance System (BRFSS) core survey and state-added LTSS questions to analyze a sample of adults with LTSS needs in Texas (N = 1232). We compared socio-demographic characteristics between adults with and without unmet LTSS needs. We conducted modified-Poisson regressions to estimate unadjusted and adjusted risk ratios (with 95 % confidence intervals) for each health/preventative healthcare outcome among adults with unmet LTSS needs. Health outcomes included health status, healthy days-physical health, healthy days-mental health, suicide ideation, and multiple chronic conditions. Preventative healthcare outcomes included routine check-up and flu vaccine.

RESULTS

Among adults with LTSS needs, those with unmet LTSS needs were statistically significantly more likely to be younger (age<65), female, higher educational attainment, and non-straight sexual orientation. After controlling for socio-demographic variables, having unmet needs for LTSS was significantly associated with poorer physical and mental health outcomes and suicide ideation.

CONCLUSIONS

Improved data collection on unmet needs LTSS can assist policymakers, particularly at the state level in guiding reforms to reduce disparities in access to home and community-based services (HCBS) and improve health outcomes.

Measuring Consumer-Reported Quality of Life Among Recipients of Publicly Funded Home- and Community-Based Services: Implications for Health Equity

OBJECTIVES

Despite an increased policy focused on home- and community-based services (HCBS), little is known about their quality of life (QoL)-a key measure of person-centered care. This paper addresses this gap by measuring consumers' self-reported QoL and identifying factors associated with disparities in QoL.

METHODS

We analyzed the 2015-2016 National Core Indicators-Aging and Disability survey for 3426 respondents in Minnesota, using factor analyses to identify latent QoL domains. Multivariable regression models identified predictors of QoL domains.

RESULTS

Factor analyses identified three valid and reliable latent QoL domains: security, self-determination, and care experiences. Younger consumers with disabilities (versus consumers ≥65 years of age), minoritized racial/ethnic groups, consumers with hearing loss, without a spouse/domestic partner, and not living in consumer's own/family home reported significantly lower QoL in various domains (p < .001).

DISCUSSION

Disparities in HCBS consumer-reported QoL exist, necessitating equitable reforms to improve HCBS quality for its increasingly diversified consumer base.

Family Involvement in the Care of Nursing Home Residents With Dementia: A Scoping Review

Family members are involved in the lives of older adults with dementia in complex ways. This scoping review synthesizes existing research on family involvement in the care of nursing home residents with advanced dementia. Using the Arksey and O'Malley scoping review framework, electronic searches of PubMed, EBSCO's CINAHL Complete, and APA PsychInfo on the Ovid platform were conducted. Twenty-eight studies met inclusion criteria. Emergent themes and definitions of involvement were obtained through thematic analysis, including: (1) contact (through visitation, calling, or writing letters); (2) engagement in care activities (instrumental/activities of daily living); (3) planning and monitoring care (being aware of health and treatment changes, partnership with care staff, ensuring adequate care, and decision-making); and (4) supporting the resident (advocacy, socioemotional support, and financial support). Moreover, limited psychometrically sound instruments exist to measure family involvement. These limitations stall the progression of research targeting family involvement.

Caregiver recruitment strategies for interventions designed to optimize transitions from hospital to home: lessons from a randomized trial

Challenges to recruitment of family caregivers exist and are amplified when consent must occur in the context of chaotic healthcare circumstances, such as the transition from hospital to home. The onset of the COVID-19 pandemic during our randomized controlled trial provided an opportunity for a natural experiment exploring and examining different consent processes for caregiver recruitment. The purpose of this publication is to describe different recruitment processes (in-person versus virtual) and compare diversity in recruitment rates in the context of a care recipient's hospitalization. We found rates of family caregiver recruitment for in-person versus virtual were 28% and 23%, respectively (p = 0.01). Differences existed across groups with family caregivers recruited virtually being more likely to be younger, white, have greater than high school education, and not be a spouse or significant other to the care recipient, such as a child. Future work is still needed to identify the modality and timing of family caregiver recruitment to maximize rates and enhance the representativeness of the population for equitable impact.

Post-acute care transitions during COVID-19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia

BACKGROUND

Differences in the post-acute care (PAC) destinations among racial, ethnic, and socioeconomic groups have been documented before the COVID-19 pandemic. Yet, the pandemic's impact on these differences remains unknown. We examined the impact of the COVID-19 pandemic on PAC destinations and its variation by individual race, ethnicity, and socioeconomic status among community-dwelling older adults with Alzheimer's disease and related dementia (ADRD).

METHODS

We linked 2019-2021 national data (Medicare claims, Minimum Data Set, Master Beneficiary Summary File) and several publicly available datasets, including Provider of Services File, Area Deprivation Index, Area Health Resource File, and COVID-19 infection data. PAC discharge destinations included skilled nursing facilities (SNFs), home health agencies (HHA), and homes without services. Key variables of interest included individual race, ethnicity, and Medicare-Medicaid dual status. The analytic cohort included 830,656 community-dwelling Medicare fee-for-service beneficiaries with ADRD who were hospitalized between 2019 and 2021. Regression models with hospital random effects and state-fixed effects were estimated, stratified by the time periods, and adjusted for the individual, hospital, and county-level covariates.

RESULTS

SNF discharges decreased while home and HHA discharges increased during the pandemic. The trend was more prominent among racial and ethnic minoritized groups and even more so among dual-eligible beneficiaries. For instance, the reduction in the probabilities of SNF admissions between the pre-pandemic period and the 2nd year of COVID was 4.6 (White non-duals), 18.5 (White duals), 8.7 (Black non-duals), and 20.1 (Black duals) percentage-point, respectively. We also found that non-duals were more likely to replace SNF with HHA services, while duals were more likely to be discharged home without HHA.

CONCLUSIONS

The COVID-19 pandemic significantly impacted PAC destinations for individuals with ADRD, especially among socioeconomically disadvantaged and racial and ethnic minoritized populations. Future research is needed to understand if and how these transitions may have affected health outcomes.

Utilization and Potential Disparities in Access to Physical Therapy for Spine Pain in the Long-Term Care Population

OBJECTIVE

To determine the frequency of physical therapy (PT) services and potential disparities in receiving PT among Medicare fee-for-service beneficiaries with a history of spine pain who live in long-term care (LTC) settings.

DESIGN

Secondary cross-sectional analysis of Medicare administrative data on beneficiaries with a history of spine pain from 2017-2019. We identified LTC residents using a validated algorithm, then identified and described PT episodes that occurred after the LTC index date. To identify potential disparities in access to PT services, we performed multivariable logistic regression to determine resident demographic, clinical, and community factors associated with receiving PT.

SETTING

Not applicable.

PARTICIPANTS

Medicare fee-for-service LTC residents aged ≥65 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Receiving PT services.

RESULTS

Of the 999,495 LTC residents with a history of spine pain, 49.6% received PT. Only 12.1% of PT episodes specifically treated spine pain. The odds of receiving PT were higher for residents with pain in multiple spine regions or neuropathic pain (OR, 1.27; 95% confidence interval CI, 1.26-1.29) and for residents with inpatient admissions (OR, 1.76; 95% CI, 1.75-1.78). Odds of receiving PT were lower for residents from minoritized racial and ethnic groups, and for residents with dementia (OR, 0.89; 95% CI, 0.88-0.90), depression (OR, 0.95; 95% CI, 0.94-0.96), or who lived in urban or more socioeconomically deprived areas.

CONCLUSIONS

Although nearly half of LTC residents with histories of spine pain received PT services, most PT was not for spine pain. There are potential disparities in access to PT for LTC residents from minoritized groups living in urban and more deprived areas. Further work should examine PT outcomes and remove barriers to PT for LTC residents with histories of spine pain.

Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias

ObjectivesAmong nursing home (NH) residents with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), racial/ethnic disparities in quality of care exist. However, little is known about quality of life (QoL). This study examines racial/ethnic differences in self-reported QoL among NH residents with AD/ADRD. Methods: Validated, in-person QoL surveys from 12,562 long-stay NH residents with AD/ADRD in Minnesota (2012-2015) were linked to Minimum Data Set assessments and facility characteristics. Hierarchical linear models assessed disparities in resident-reported mean QoL score (range, 0-100 points), adjusting for case-mix and facility factors. Results: Compared to White residents, racially/ethnically minoritized residents reported significantly lower total mean QoL scores (75.53 points vs. 80.34 points, p < .001). After adjustment for resident- and facility-level characteristics, significant racial/ethnic differences remained, with large disparities in food enjoyment, attention from staff, and engagement domains. Discussion: Policy changes and practice guidelines are needed to address racial/ethnic disparities in QoL of NH residents with AD/ADRD.

Exploring Overt Racial and Ethnic Conflict in Resident-to-Resident Aggression in Long-Term Care Facilities

Objectives

Resident-to-resident aggression (RRA) in long-term care facilities is gaining recognition as a serious problem. Racial/ethnic conflict may be a contributing factor to RRA incidents, but it remains insufficiently studied. Our goal was to explore overt racial/ethnic conflict in RRA.

Design

We used quantitative and qualitative secondary analyses of existing data from a large, rigorously conducted study of RRA to describe the involved residents and patterns of overt racial/ethnic conflicts.

Setting and Participants

The parent study included information of 2011 residents in 10 randomly selected New York State nursing homes with a wide range of racial/ethnic minority residents (4.2%-63.2%). A subset of 407 residents were involved in RRA.

Methods

We re-examined data from the parent study, which used an innovative approach to identify RRA incidents by reconstructing each incident based on residents' self-reports, staff interviews, field observations, and medical chart review. Resident and facility information was collected.

Results

A total of 35 residents (8.6% of those involved in RRA incidents) were identified as involved in overt racial/ethnic conflicts. These residents were more likely to have had less education than residents involved in other types of RRA but not in overt racial/ethnic conflicts. More than half (56.9%) of the 51 incidents of RRA involving overt racial/ethnic conflict between a specific pair of residents occurred repeatedly. Manifestation of racial/ethnic conflicts included physical violence, discrimination, racial/ethnic slurs, stereotypes, and microaggression. Acute precipitants of these incidents included various communal-living challenges and unmet needs at the facility, relational, and individual levels. Psychological and behavioral consequences were also described.

Conclusion and Implications

We found a broad range of manifestations, acute precipitants, circumstances surrounding, and consequences of overt racial/ethnic conflicts in RRA. Additional research is needed to improve understanding of this phenomenon and how staff may effectively intervene and prevent it.

Linking Medicare-Medicaid Claims for Patient-Centered Outcomes Research Among Dual-Eligible Beneficiaries

BACKGROUND

Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation.

OBJECTIVE

To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries.

RESEARCH DESIGN

We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data.

PARTICIPANTS

North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017.

MEASURES

We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS).

RESULTS

Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older.

CONCLUSIONS

Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.

The Role of Place in Person- and Family-Oriented Long-Term Services and Supports

Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions.

CONTEXT

Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them.

METHODS

We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status.

FINDINGS

We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations.

CONCLUSIONS

We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.

Proposing A Racism-Conscious Approach To Policy Making And Health Care Practices

Racial and ethnic health inequities are driven by multiple social and political factors. Race-neutral policies that overlook the role of racism in policy and in disparities may also contribute to inequities. In response, one broad policy-making approach has been to craft race-based policies that attempt to improve outcomes explicitly for specific racial groups. However, race-based policies can be politically infeasible. We propose a racism-conscious approach to policy making and health care practices that addresses racism and advances health equity. Using postacute and long-term care policies as a backdrop, we identify five key steps to creating racism-conscious policies that rest on continuous community engagement and policy evaluation. The proposed racism-conscious framework can be used to develop a new health policy or to redesign an existing policy, and it can work for federal, state, local, and organizational policies, practices, or both.

Building the Geropsychology Workforce: A National Survey and Virtual Conference Define Critical Obstacles and Steps Forward

The number of psychologists prepared to work with older adults falls far short of the demand. In the face of perceptions of a worsening geriatric workforce shortage, we describe the process of developing and implementing a national virtual conference aimed at generating solutions. A preconference survey (n = 174) found fewer applicants than desirable for aging-targeted graduate student, trainee, clinician, or academic positions (58.6%) and decreased student interest in aging (43.7%), with downstream consequences of filling age-targeted positions by those without aging backgrounds (32.3%), difficulty securing funding for aging-related positions (28.7%), and loss of aging-related positions (27.0%). Two fifths (40.7%) felt these problems have worsened as compared to 5 years ago. Qualitative responses provide detailed perspectives on these barriers and strategies generally and in particular as relates to racial and ethnic diversity and academic geropsychology. During a 2-day conference, attendees developed and prioritized strategies. Following a postconference survey to ascertain interest in volunteering, seven work groups were formed that have made progress on these issues. A virtual conference provides an inclusive, cost-effective, and fruitful opportunity to discuss workforce concerns in geropsychology and to generate numerous ideas to promote positive change.

Caring for aging parents in the last years of life

BACKGROUND

Adult children provide a large portion of end-of-life caregiving for older adults and make up the majority of caregivers for adults with dementia. Yet research has been limited to the hours of care that primary caregivers provide, neglecting the other ways adult children provide caregiving support. This study aims to describe the caregiving support adult children provide to their parents at the end of life and characterize differences by race and ethnicity and dementia status.

METHODS

We conducted a retrospective study using survey responses from the Health and Retirement Study between 2002 and 2018. The sample population (n = 8040) included decedents aged 65 with at least one living adult child at their time of death. Caregiving support was defined as providing financial support, providing help with basic or instrumental activities of daily living (ADLs or IADLs), or coresiding with the care recipient. Respondents were stratified by self-identified race and ethnicity as Hispanic, non-Hispanic White, or non-Hispanic Black. Respondents were further stratified by dementia and marital status.

RESULTS

Black and Hispanic respondents without dementia were more likely to report receiving financial help from (28.0% and 25.9%) or coresiding with their adult children (38.9% and 49.7%) compared to White respondents (15.0% receiving financial help and 23.3% coresiding) (p < 0.05). Among respondents with dementia, 47.1% of both Black and Hispanic respondents reported coresiding with their adult children, compared to only 24.6% of White respondents (p < 0.05). Notably, married Black and Hispanic respondents reported significantly higher rates of all support types compared to married White respondents (p < 0.05).

CONCLUSIONS

The majority of older adults at the end of life receive some form of care and support from their adult children, with Black and Hispanic older adults receiving particularly high rates of care and support from their adult children regardless of dementia or marital status.

The Role of Trust in Older Adult Service Provision at the Onset of the COVID-19 Pandemic

The COVID-19 pandemic caused near immediate service delivery adaptation among social service and healthcare sectors. Findings from in-depth interviews with 45 senior leaders of social services and healthcare organizations serving older adults in Washington State elucidate the role of trust in service provision at the onset of the pandemic. First, a history of trust facilitated service adaptation. Intentional outreach, programs, and culturally responsive services sustained trust with service recipients. Providing services and information in an older adult's preferred language built trust. Community networks facilitated and reflected trust between organizations and older adults. Finally, mistrust was prevalent for clients who perceived a high risk of experiencing negative consequences from accessing services. Our findings support the need for culturally and linguistically diverse services. To improve trust, the aging network should strengthen and expand partnerships with community-based organizations who have established trust through history, intentionality, and relevance to their service populations..

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

CONTEXT

Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors.

METHODS

We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design.

FINDINGS

After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use.

CONCLUSIONS

Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

Engaging Sexual and Gender Minority Older Adults to Elicit Concerns and Recommendations for Communicating Care Preferences in Long-Term Care: Focus Group Findings

OBJECTIVES

1) Describe sexual and gender minority (SGM) older adults' current practices and concerns for communicating end-of-life (EOL) and daily care preferences in long-term care (LTC); 2) Elicit ideas about adapting a video-based intervention to facilitate communication.

METHODS

After consulting a community advisory board, we conducted two focus groups with SGM older adults ≥55 years of age recruited from a community-based service organization (n = 4) and a continuing care retirement community (n = 9). We audio-recorded, transcribed, and coded data using directed content analysis methods and summarized results descriptively.

RESULTS

Most participants were cisgender (n = 12), female (n = 11), lesbian (n = 10), White and non-Hispanic (n = 13); mean age was 70.62. Participants' concerns included discrimination, autonomy, chosen family, and community; they linked daily care preferences with personhood and quality of life. They advocated for building intentional community-based support networks to help peers discuss preferences and produce videos before LTC transition and ensure compliance after.

CONCLUSIONS

For SGM older adults, asserting and protecting their full personhood, through daily care preferences, is essential to quality of life in LTC.

CLINICAL IMPLICATIONS

Video-recorded statements of daily preferences, facilitated and supported by a peer network, could promote culturally competent, person- and community-centered care for SGM older adults in LTC settings.

"I Have a Lotta Sad Feelin'" - Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

OBJECTIVE

To investigate mental health needs and barriers to seeking mental health support in Medicaid-funded Assisted Living Facility (M-ALF).

DESIGN

A multimethod, qualitative-dominant descriptive design using questionnaires and semistructured interviews.

SETTING AND PARTICIPANTS

The study occurred at a M-ALF in the Bronx, New York. A researcher in residence recruited 13 residents (11 Black or African American, 2 Asian) using purposive sampling.

METHODS

Demographic data and mental health indicators (depression, anxiety, stress, hopelessness) were measured with questionnaires (Center for Epidemiological Studies Depression Scale, Edmonton Symptom Assessment System, Perceived Stress Scale, Beck Hopelessness Survey) and analyzed with descriptive statistics. Interviews were conducted between June and November 2021, transcribed, and analyzed using conventional content analysis.

RESULTS

Thirteen residents (mean age: 73.4 years, mean length of stay: 3.5 years; range: 1.0-7.5) completed data collection. Quantitatively indicators of unmet mental health were common. Qualitatively, residents reported barriers to mental health access to address depression, anxiety, and substance use. This was accompanied by concerns surrounding loss of autonomy, mistrust for M-ALF organizational support, isolation and uncertainty about how to receive mental health support. Perspectives were shaped by past experiences with institutional living, serious illness, and being unhoused. Themes and subthemes were (1) mental health need (unmet mental health need, depression, and anxiety and seeking support through non-mental health resources) and (2) barriers to mental health support (dissatisfaction with M-ALF care, perceived threats to autonomy, desire for autonomy that leads to diminished care seeking).

CONCLUSION AND IMPLICATIONS

Residents of M-ALF have mental health needs for which care is stymied by loss of autonomy, lack of resources, and the M-ALF environment. Residents use unconventional resources to address needs that may be neither efficient nor effective. Novel mental health interventions and processes are needed to improve mental health access and should prioritize residents' desire for autonomy and the unique circumstances of living in M-ALF.

The Right to Science: Centering People With Intellectual Disability in the Process and Outcomes of Science

The right to science has been identified in multiple human rights treaties; however, there has not been a clear framework for how governments or research organizations can advance this right particularly ensuring equitable engagement of people with intellectual disability (ID) in the process of scientific research. Although the feasibility and impacts of engaging people with ID in the process of science have been repeatedly demonstrated there remain systemic barriers including ableism, racism, and other systems of oppression that sustain inequities. Researchers in the ID field must take steps to dismantle systemic barriers and advance participatory approaches that advance equity in the process and outcomes of science.

Identifying Nursing Homes With Diverse Racial and Ethnic Resident Compositions: The Importance of Group Heterogeneity and Geographic Context

Racial/ethnic composition of nursing home (NH) plays a particularly important role in NH quality. A key methodological issue is defining when an NH serves a low versus high proportion of racially/ethnically diverse residents. Using the Minimum Data Set from 2015 merged with Certification and Survey Provider Enhanced Reports, we calculated the racial/ethnic composition of U.S.-based NHs for Black or Hispanic residents specifically, and a general Black, Indigenous, and People of Color (BIPOC) grouping for long-stay residents. We examined different definitions of having a high racial/ethnic composition by varying percentile thresholds of composition, state-specific and national thresholds, and restricting composition to BIPOC residents as well as only Black and Hispanic residents. NHs with a high racial/ethnic composition have different facility characteristics than the average NH. Based on this, we make suggestions for how to identify NHs with diverse racial/ethnic resident compositions.

Understanding Nursing Home Spending And Staff Levels In The Context Of Recent Nursing Staff Recommendations

To provide context for evaluating proposed nursing home staff regulations, we examined the proportion of facility revenues spent on nursing staff, as well as nursing staff levels in hours worked and paid per resident day, in 2019. Nationally, the median proportion of revenues spent on nursing staff was 33.9 percent, and median nursing staff levels were 3.67 hours worked and 4.08 hours paid per resident day. Facilities with higher shares of Medicaid residents spent a larger share of revenues on nursing staff but had lower staffing levels. States varied significantly with respect to median spending on nursing staff (26.8-44.0 percent of revenues) and median nursing staff levels (3.2-5.6 hours worked and 3.6-5.7 hours paid per resident day). These findings indicate that raising the proportion of revenues spent by nursing homes on nursing staff to a regulated minimum would not guarantee the achievement of adequate nursing staff levels unless it was paired with other regulatory mechanisms.

Quality at nursing homes with high proportion of residents with cognitive impairment

INTRODUCTION

There is limited data on staffing ratings at nursing homes (NHs) serving residents with dementia, despite staffing impacting quality of care.

METHODS

Residents' cognitive impairment status, staffing rating, and facility characteristics were obtained for 11,469 NHs, using data from the Centers for Medicare & Medicaid Services and Long-term Care: Facts on Care in the U.S. The association between the proportion of residents with cognitive impairment and nurse staffing rating was analyzed using multiple logistic regression in a cross-sectional study design.

RESULTS

NHs with a high proportion of residents with cognitive impairment were 41% less likely to have a high staffing rating or high RN staffing rating (95% CI: 0.52-0.67) compared to NHs with a low proportion.

DISCUSSION

NHs that serve a higher proportion of residents with cognitive impairment have lower staffing ratings, and this disparity is more pronounced in NHs with more minority residents. Increasing staffing levels is a necessary policy measure to improve care in these facilities.

Neither Race nor Ethnicity Impact the Mortality of Residents of Veterans Affairs Community Living Center With COVID-19

OBJECTIVES

COVID-19 disproportionately affected nursing home residents and people from racial and ethnic minorities in the United States. Nursing homes in the Veterans Affairs (VA) system, termed Community Living Centers (CLCs), belong to a national managed care system. In the period prior to the availability of vaccines, we examined whether residents from racial and ethnic minorities experienced disparities in COVID-19 related mortality.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Residents at 134 VA CLCs from April 14 to December 10, 2020.

METHODS

We used the VA Corporate Data Warehouse to identify VA CLC residents with a positive SARS-CoV-2 polymerase chain reaction test during or 2 days prior to their admission and without a prior case of COVID-19. We assessed age, self-reported race/ethnicity, frailty, chronic medical conditions, Charlson comorbidity index, the annual quarter of the infection, and all-cause 30-day mortality. We estimated odds ratios and 95% confidence intervals of all-cause 30-day mortality using a mixed-effects multivariable logistic regression model.

RESULTS

During the study period, 1133 CLC residents had an index positive SARS-CoV-2 test. Mortality at 30 days was 23% for White non-Hispanic residents, 15% for Black non-Hispanic residents, 10% for Hispanic residents, and 16% for other residents. Factors associated with increased 30-day mortality were age ≥70 years, Charlson comorbidity index ≥6, and a positive SARS-CoV-2 test between April 14 and June 30, 2020. Frailty, Black race, and Hispanic ethnicity were not independently associated with an increased risk of 30-day mortality.

CONCLUSIONS AND IMPLICATIONS

Among a national cohort of VA CLC residents with COVID-19, neither Black race nor Hispanic ethnicity had a negative impact on survival. Further research is needed to determine factors within the VA health care system that mitigate the influence of systemic racism on COVID-19 outcomes in US nursing homes.

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.

Implementation of a CMS Nursing Facility Initiative: Differences by Racial Minority Resident Population

Objectives: The CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Payment Reform (NFI 2) provided billing opportunities to incentivize participating facilities to keep long-stay residents onsite for acute care, rather than hospitalizing them. We examined cross-facility differences in NFI 2 implementation by racial composition of facility resident populations. Methods: We analyzed Medicare claims in conjunction with in-person and telephone interviews among facility staff to assess NFI 2 engagement in relation to racial minority resident population. Results: Participating facilities with larger racial minority resident populations faced additional barriers to NFI 2 implementation. These facilities submitted fewer NFI 2 claims, reported more challenges engaging resident families, and experienced greater facility staff and leadership instability, compared to facilities with predominantly white resident populations. Discussion: Addressing structural differences within facilities with larger populations of racial minority residents may encourage future development of targeted programs to support diverse nursing facilities.

Essential but Excluded: Building Disaster Preparedness Capacity for Home Health Care Workers and Home Care Agencies

COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care.

Chart based data as a resource for tracking and improving a person-centred palliative approach in long-term care

AIMS AND OBJECTIVES

To enhance the practice of a person-centred palliative approach in long-term care.

BACKGROUND

Implementing a person-centred palliative approach in long-term care entails placing residents at the centre of care planning that attends to the 'whole' person, rather than prioritising biomedical needs.

DESIGN

We conducted a four-stage directed content analysis of long-term care progress notes to meet our study aims and applied the EQUATOR guidelines for qualitative research publication (COREQ).

METHODS

We qualitatively analysed 78 resident charts across three long-term care homes in southern Ontario to capture the extent to which person-centred care was absent, initiated or implemented in different types of documented care interactions.

RESULTS

Most residents had interactions related to daily care activities (65/78, 83%), social concerns (65/78, 83%) and treatment decisions (53/78, 68%). By contrast, interactions around pain and discomfort (34/78, 44%) and spirituality (27/78, 35%) were documented for less than half of the residents. Almost all (92%) residents had at least one progress note where staff initiated person-centred care by documenting their preference for a certain type of care, but only a third had at least one progress note that suggested their preference was implemented (35%).

CONCLUSIONS

While person-centred care is often initiated by nurses and other allied health professionals, changes to care plans to address resident preferences are implemented less often. Nurses and other allied health professionals should be encouraged to elicit care preferences crucial for holistic care planning and equipped with the skills and support to enact collaborative care planning.

RELEVANCE TO CLINICAL PRACTICE

Collaborative care planning appears relatively absent in charted progress notes, constraining the full implementation of a person-centred palliative approach to care.

PATIENT OR PUBLIC CONTRIBUTION

An advisory group consisting of long-term care resident and staff representatives informed the overall study design and dissemination of the results.