Variation in Older Americans Act caregiver service use, unmet hours of care, and independence among Hispanics, African Americans, and Whites

Lessons from a Pilot Study of a Culturally Tailored Financial Well-Being Intervention Among Latino Family Caregivers

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov (NCT05292248).

Disparities in Physical Therapy Outcomes Based on Race and Ethnicity: A Scoping Review

OBJECTIVE

This scoping review synthesizes and summarizes the evidence on racial and ethnic disparities in outcomes after physical therapist treatment.

METHODS

Four databases from 2001 through 2021 were searched for articles reporting physical therapy outcomes across racial and ethnic groups. The Arksey and O'Malley methodological framework was adapted for this scoping review. Two reviewers screened the abstracts, and 5 reviewers screened full texts for inclusion. Five reviewers extracted information including study design, diagnoses, setting, outcomes reported, the domains the outcomes measured, and racial and ethnic groups included. To identify disparities, summarized differences in outcomes (better, worse, no difference) for each racial and ethnic group compared to White patients were calculated.

RESULTS

Of 1511 abstracts screened, 65 met inclusion criteria, 57 of which were observational designs. All 65 articles included non-Hispanic White patients as the reference group. A majority of the physical therapy outcomes reported by race were for Black patients and/or Hispanic or Latino patients, whereas outcomes for Asian, American Indian, Alaskan Native, and/or Native Hawaiians or Pacific Islander patients were reported infrequently. Most articles reported disparities in health outcomes for patients in the inpatient rehabilitation setting (n = 48) and for adults (n = 59) with neurologic diagnoses (n = 36). Compared to White patients, worse outcomes were reported more frequently for all marginalized racial and ethnic groups after physical therapy, with the exception of marginalized groups having the same or better outcomes for successful post-rehabilitation community discharge.

CONCLUSION

Gaps remain in understanding outcome disparities beyond older adult and neurologic populations as well as for musculoskeletal diagnoses frequently treated by physical therapists.

IMPACT

The presence of racial and ethnic disparities in physical therapy outcomes should motivate physical therapists to understand the mechanisms underlying disparities and focus on social and structural drivers of health inequity in their clinical decision-making.

The relationship between dementia caregivers and quality of life in South Korean populations

The purpose of this study was to assess the relationship between quality of life and dementia caregivers. The 2019 Korean Community Health Survey participants were assessed using the Patient Health Questionnaire-9, subjective cognitive decline (SCD) and SCD-related functional limitation, and EuroQol 5-dimension (EQ-5D). Sociodemographic and psychosocial variables were evaluated and compared between participants with dementia caregivers (n = 37,614) and non-dementia caregivers (n = 140,518). The dementia caregivers group reported significantly higher rates of depression, SCD, SCD-related functional restriction, and mean EQ-5D compared to the non-dementia caregivers group (P < .001). After adjusting for multiple confoundings, the odds ratio (OR) for depression (Patient Health Questionnaire-9 ≥ 10), SCD, SCD-related functional limitation, and lowest quartile of the EQ-5D index scores in the dementia caregivers group were 1.43 (95% confidence interval [CI], 1.29-1.59), 1.30 (95% CI: 1.24-1.36), 1.26 (95% CI: 1.20-1.32), and 1.22 (95% CI: 1.16-1.29), respectively. Physical activity (OR: 1.47; 95% CI: 1.43-1.52), self-control (OR: 1.41; 95% CI: 1.35-1.47), daily activity (OR: 1.55; 95% CI: 1.50-1.60), pain (OR: 1.62; 95% CI: 1.58-1.67), and anxiety/depression (OR: 2.17; 95% CI: 2.10-2.24) were all more common among participants in the dementia caregivers group than in the non-dementia family caregivers group. Depression, SCD, and a lower quality of life are linked to dementia caregivers, especially if there is moderate to severe anxiety or depression.

Examining Satisfaction and Quality in Home- and Community-Based Service Programs in the United States: A Scoping Review

BACKGROUND AND OBJECTIVES

Long-term services and supports in the United States are increasingly reliant on home- and community-based services (HCBS). Yet, little is known about the quality of HCBS. We conducted a scoping review of the peer-reviewed literature to summarize HCBS consumer, provider, and stakeholder satisfaction with services as a means of assessing quality.

RESEARCH DESIGN AND METHODS

We searched PubMed, OVID-MEDLINE, and SCOPUS to identify articles published from 2000 to 2021 that reported on studies describing a U.S.-based study population. Articles were grouped into 3 categories: drivers of positive consumer satisfaction, drivers of negative consumer satisfaction, and provider and stakeholder perspectives on satisfaction.

RESULTS

Our final sample included 27 articles. Positive perceptions of quality and reported satisfaction with services were driven by consistent, reliable, and respectful care providers, and adoption of person-centered models of service delivery. Mistreatment of consumers, staff turnover, training, service interruptions, and unmet functional needs were drivers of negative consumer perceptions of quality. Support for caregivers and emphasis on training were identified by providers and stakeholders as important for providing satisfactory services.

DISCUSSION AND IMPLICATIONS

Multiple data challenges limit the ability to systematically evaluate HCBS program quality; however, studies examining single programs found that HCBS consumers are more satisfied and associate higher quality with easy-to-navigate programs and professional staff. Efforts to expand HCBS should also include requirements to systematically evaluate quality outcomes.

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..

Duration of Dementia and Social Service Use in the U.S.-Born and Foreign-Born Mexican-American Population

Objective

The study estimates the number of years after age 65 that Mexican Americans live with likely dementia and the impact of dementia on community-based services (CBS) use by nativity.

Methods

Using the Hispanic Established Populations for the Epidemiologic Studies of the Elderly Sullivan methods are employed to predict duration of dementia and logistic regressions identify the predictors of service utilization.

Results

Foreign-born women spend more years than other groups with dementia. The foreign-born are more likely to use out-of-home services, whereas U.S.-born are more likely to use in-home services. The foreign-born with dementia of relatively recent onset had the highest probability of service use.

Discussion

Given the high cost of institutional care and availability of family caregivers, community-based services are a potentially useful alternative for the growing Mexican-American population living with dementia. Expanded Medicaid and CBS programs could be an equitable and cost-effective alternative that should be investigated.

Care v. Caring: Obligation, Duty, and Love Among Latino Alzheimer's Family Caregivers

The number of Latinos living with Alzheimer's disease is projected to grow. Latinos currently make one-fifth of U.S. family caregivers. In this paper, we explore the cultural scripts and gendered practice of care in Latino families in relation to the underutilization of services to persons with Alzheimer's disease and related dementias. We conducted interviews with 24 Latino caregivers in Miami-Dade, Florida representing six Latin American countries of origin. Interviews were analyzed using a grounded theory approach. We critically examined the concept of familism in order to better understand in-depth experiences of diverse Latino caregivers and concluded that an ethics of care model better elucidates the complexities of the care experience. Our analysis illustrates the ambivalence, contradictions, and changes in the beliefs and practice of care. These findings can help advance understanding among researchers and providers to develop a formal support system that is responsive to Latino caregiver needs.

The Experience of Alzheimer's Disease Family Caregivers in a Latino Community: Expectations and incongruences in support services

OBJECTIVES

Current theoretical constructs on the utilization of formal support for Latino caregivers focus on familism and exclude the cultural values represented in the service system. The purpose of this paper is to highlight the experience of care for Latino family caregivers to persons with Alzheimer's disease and related dementias (ADRD). We also examine the cultural congruence between provider perspectives with the expectations of Latino ADRD caregivers.

METHOD

We conducted extended interviews with 24 Latino ADRD caregivers and 10 service providers. Interview transcripts were coded and analyzed using a grounded theory approach.

RESULTS

Our study provides a deeper understanding of Latino caregiving experiences and highlights some of the structural and systematic issues in current systems of caregiver support. While Latino families have very specific notions of care, by upholding notions of familism, there is a tendency to not look deeper into how they may be better supported in caregiving and fall into the "culture trap." The assumption that family should be the natural support network for older adults may lead to health and social systems of care to ignore the specific needs of the Latino population.

DISCUSSION

Services are being provided under a model that was established four decades ago and may not reflect current realities. The concept of "an ethics of care" allows us to move beyond familism and explain that underutilization of services may also be due in part to the cultural incongruence between what service providers offer and the perceived needs of Latino caregivers.

Long-Term Care Options in Florida: Their Availability by County Demographics

Older people express a preference for home and community-based care over skilled nursing, realizing that preference, however, is dependent upon having those options available. The present exploratory study uses publicly available data to understand if the geographic availability of long-term care options-skilled nursing, assisted living, home health, and homemaker/companion services-are equally distributed by demographics in Florida. Regression analyses showed that the percent 65 and older and the percent in poverty in a county were not related to long-term care availability or quality. Findings indicate that Hispanic older people have less access to nursing home beds, greater access to home health and homemaker/companion agencies, and tend to live in counties with a greater number of assisted living facility (ALF) deficiencies while Black older people have greater access to homemaker services. Rural counties had lower rates of home health and homemaker/companion agencies and fewer ALF deficiencies. The 65 and older population would benefit from the increased availability of long-term care options near the communities in which they live.

Use of Informal Support as a Predictor of Home- and Community-Based Services Utilization

OBJECTIVES

Home- and community-based services (HCBS) help older adults remain living safely in their homes by delaying or preventing the need for institutionalization. This analysis is guided by the Andersen Behavioral Model of Health Services Use to examine the association between informal support and use of HCBS.

METHOD

Health and Retirement Study data from 2011 and 2012 are used in the bivariate analyses and multivariate logistic regression models to examine differences in HCBS utilization among extremely vulnerable older adults who have informal caregivers and those who do not.

RESULTS

For extremely vulnerable older adults who report difficulties with any instrumental or basic activities of daily living, use of HCBS is not strongly associated with access to informal caregivers. However, for this same population of extremely vulnerable older adults, those who live alone have roughly 3 times the odds of using any HCBS compared to those who do not live alone.

DISCUSSION

Among already vulnerable older adults, this study revealed that living alone is an important enabling factor of the Andersen Behavioral Model as applied in HCBS research. Further investigation is needed to see if more resources should be allocated to senior centers and local providers to identify vulnerable older adults who live alone and may have unmet needs.

The Supporting Older Americans Act of 2020: How Policy Connects With Occupational Therapy Principles and Practice

The U.S. population is aging at an unprecedented rate, creating both opportunities and challenges for the overall health of the nation. Occupational therapy practitioners can inform important health policies by developing an understanding of the basis for relevant laws and programs and how occupational therapy principles relate to policy goals. This column discusses the Older Americans Act of 1965 (reauthorized as the Supporting Older Americans Act of 2020) and describes ways in which the objectives of this legislation align with the principles and practice of occupational therapy. Recommendations are provided for how the field of occupational therapy can enhance current policy development and debate, thus leading to expanded opportunities for the profession.

Racial/Ethnic Differences in Caregiving Frequency: Does Immigrant Status Matter?

Objectives

With growing diversity in the older adult and caregiver populations, the purpose of the current study is to describe the extent to which elder care frequency varies by race/ethnicity and immigrant/native status using national data from the United States.

Method

Using pooled data from the 2011-2014 American Time Use Surveys (ATUS; N = 7,855), we present multinomial logistic regressions of caregiving frequency by race/ethnicity and immigrant/native status and explore whether factors within the caregiving domain (duration of care, number of care recipients, and coresidence) attenuate any observed differences.

Results

Compared to non-Latino Whites, non-Latino Black, Mexican-origin, and other Latino caregivers engage in more frequent elder care activities, which is partially attributable to high levels of coresidence among these subpopulations. Although immigrant caregivers, in general, tend to engage in more time-intensive caregiving, for Mexican-origin and other Latino caregivers, U.S.-born caregivers report more frequent elder care provision.

Discussion

More time-intensive and demanding caregiving careers reported by racial/ethnic minority and immigrant caregivers further emphasize the need for culturally competent home- and community-based care options.

What Are the Characteristics of Caregivers Logging in for Support Services?

Background and Objectives

Online service delivery options have the potential to increase access to informational resources among caregivers to older adults. However, it is unknown which caregivers will use online-delivered services over usual service delivery modes (e.g., by phone) when both options are available in social service settings. This is important for service providers to know when making decisions that best serve their communities.

Research Design and Methods

Guided by Andersen's model of health service utilization, we used step-wise logistic regression models to compare the characteristics of caregivers who used an online information service called FCA CareJourney (FCA CJ) with those who accessed the same services using the usual mode of service delivery (N = 540). Online and usual-care services were available through two social service organizations in California.

Results

In all, 13.7% of clients used FCA CJ to receive services online. Enabling characteristics were the main predictors of using online-delivered services. Caregivers employed part-time had 3.82 times the odds of using online-delivered services compared to those employed full-time (odds ratio [OR] = 3.82; 95% confidence interval [CI]: 1.58-9.22). Caregivers who learned about services from health care providers had 2.91 times the odds of using FCA CJ as those who learned about services through social services (OR = 2.91; 95% CI: 1.28-6.62). Even among those who learned about services online, 62.2% still accessed services using usual delivery modes.

Discussion and Implications

Based on differences in the characteristics of caregivers using different service delivery modes and the low uptake of online-delivered services, we suggest online service delivery should supplement, not replace, usual delivery modes in social service settings. At the same time, user rates of online service delivery are likely modifiable. Given the potential for online-delivered programming to expand access to information services for caregivers, we recommend further examination into the effects of marketing online service delivery options to caregivers in novel ways.

Understanding the educational and support needs of informal care-givers of people with dementia attending an outpatient geriatric assessment clinic

Informal (unpaid) care-givers of older people with dementia experience stress and isolation, causing physical and psychiatric morbidity. Comprehensive geriatric assessment clinics represent an important geriatrician-led model of dementia care. Our qualitative study examined the educational and support needs of care-givers of people diagnosed with dementia at a geriatric assessment clinic, resources used to address those needs and challenges experienced in doing so. We conducted structured thematic analysis of interviews with 18 informal care-givers. Participants’ narratives reflected four themes. First, care-givers sought information from varied sources, including the Alzheimer Society, the internet and clinic staff. Responsive behaviours, the expected progression of dementia and system navigation were topics of particular interest. Second, care-givers obtained assistance from public, for-profit and voluntary sources. Third, care-givers received little assistance. Two-thirds received fewer than four hours of help weekly from all sources combined, and none more than 15. Several received no assistance whatsoever. Publicly funded support workers’ tasks, and their timing, were often unhelpful. Finally, while numerous care-givers felt physical and emotional strain, and worried about how poor health impaired their care-giving, many hesitated to seek help. The needs of this unique population of informal care-givers can be met by improved home-care service flexibility, and access to trustworthy information about the expected progression of dementia and skills for managing behavioural and psychological symptoms.

The Trump Administration's assault on health and social programs: potential consequences for older Hispanics

Health and social welfare policy proposals put forth by the Trump administration and Republican-controlled Congress could have huge impacts on low-income groups. This paper focuses on older Hispanics, with an emphasis on the Mexican-origin population who form the largest Hispanic subgroup. A demographic portrait is presented that indicates that Mexican-origin individuals have less wealth and lower incomes than do non-Hispanic Whites. Given rising health care costs, lower use of nursing homes, and greater propensity to live with grown children, prevailing economic disadvantage has serious consequences for this population. More restrictive immigration policies aimed at limiting family reunification could have intergenerational caregiving consequences. In addition, because of labor-force disadvantages, low-income Mexican-origin adults are less likely to have private insurance compared to non-Hispanic Whites as they approach retirement. Consequently, Mexican-origin older adults tend to rely on Medicaid when eligible; in contrast, late-life migrants-who do not qualify for federally funded benefits for at least five years-and unauthorized migrants-who are excluded from federally funded benefits-have extremely limited access to safety net provisions. The potential effects of proposed cutbacks in health care financing on older Hispanics are discussed.

Factors Associated With Caregivers' Use of Support Services and Caregivers' Nonuse of Services Sought

Informal caregivers may face barriers accessing services like respite care, training, and support groups. Using multinomial logistic regression, I modeled caregivers' probability of using all services sought ("all services used") and nonuse of any services sought ("any unused services") as a function of caregiver and care-recipient characteristics. Care-recipient health and function, especially dementia and need for medical task assistance, were associated with all services used and any unused services, and any unused services were more likely among adult children caring for their parents, caregivers of Black and Hispanic older adults, caregivers providing intensive care, caregivers living in metropolitan areas, and residents of states that spend more on increasing access to caregiver services under the National Family Caregiver Support Program. Regularly scheduled caregiving was associated with higher likelihood of all services used, but not with any unused services. Steps should be taken to increase access for caregivers who provide intensive care, care to dementia patients, or assistance with medical tasks and for Hispanic families.

Objective and Subjective Cognitive Problems among Caregivers and Matched Non-caregivers

Purpose of the study

Caregivers (CGs) have been shown to do more poorly than non-caregivers (NCGs) on objective cognitive tests (Trails B and Digit Symbol Test, DST), but less is known about whether these groups differ in: (a) reports of subjective cognitive problems (SCPs, memory complaints, etc.) and (b) relationships of SCPs with objective cognitive tests, depression, and stress exposure. Such relationships are important because researchers/clinicians use SCPs as proxies for objective cognitive tests.

Design and methods

One hundred and twenty-two spouse CGs of persons with Alzheimer's disease and 117 demographically matched NCG spouses were compared on Trails B and DST at baseline (T1), 1 year later (T2), and 2 years later (T3) and on SCPs at T1.

Results

Trails B was slower in CGs than NCGs and DST declined in CGs relative to NCGs. CGs reported more SCPs than NCGs. Depression mediated group differences in Trails and DST and was also associated with SCPs. Trails B and DST explained variance in SCPs in NCGs, but not in CGs. Hours of care explained variance in SCPs in CGs, but not in NCGs.

Implications

When using SCPs to make inferences about CG cognitive function, researchers/clinicians should consider the possible influence of stress exposures and depression. The lack of associations of objective and subjective cognitive measures may be a reflection of poorer self-monitoring among CGs, a potential new area of CG research.

How do race and Hispanic ethnicity affect nursing home admission? Evidence from the Health and Retirement Study

OBJECTIVES

This study investigates how health- and disability-based need factors and enabling factors (e.g., socioeconomic and family-based resources) relate to nursing home admission among 3 different racial and ethnic groups.

METHOD

We use Cox proportional hazard models to estimate differences in nursing home admission for non-Hispanic whites, non-Hispanic blacks, and Hispanics from 1998 to 2010 in the Health and Retirement Study (N = 18,952).

RESULTS

Racial-ethnic differences in nursing home admission are magnified after controlling for health- and disability-based need factors and enabling factors. Additionally, the degree to which specific factors contribute to risk of nursing home admission varies significantly across racial-ethnic groups.

DISCUSSION

Our findings indicate that substantial racial and ethnic variations in nursing home admission continue to exist and that Hispanic use is particularly low. We argue that these differences may demonstrate a significant underuse of nursing homes for racial and ethnic minorities. Alternatively, they could signify different preferences for nursing home care, perhaps due to unmeasured cultural factors or structural obstacles.

Gender Differences in Institutional Long-Term Care Transitions

INTRODUCTION

This study investigates the relationship between gender, the likelihood of discharge from institutional long-term care (LTC) facilities, and post-discharge living arrangements, highlighting sociodemographic, health, socioeconomic, and family characteristics.

METHODS

We use the Health and Retirement Study to examine individuals age 65 and older admitted to LTC facilities between 2000 and 2010 (n = 3,351). We examine discharge patterns using survival analyses that account for the competing risk of death and estimate the probabilities of post-discharge living arrangements using multinomial logistic regression models.

RESULTS

Women are more likely than men to be discharged from LTC facilities during the first year of stay. Women are more likely to live alone or with kin after discharge, whereas men are more likely to live with a spouse or transfer to another institution. Gender differences in the availability and use of family support may partly account for the gender disparity of LTC discharge and post-discharge living arrangements.

CONCLUSION

Our findings suggest that women and men follow distinct pathways after LTC discharge. As local and federal efforts begin to place more emphasis on the transition from LTC facilities to prior communities (e.g., transitional care initiatives under the Patient Protection and Affordable Care Act), policymakers should take these gender differences into account in the design of community transition programs.

Nativity status and sources of care assistance among elderly Mexican-origin adults

Much like other racial/ethnic groups, Latinos are facing challenges to provide needed care to aging adults. Older Latinos underutilize nursing homes and home health care services and primarily rely on their families for assistance. While this general trend has been established, little attention has been paid to nativity differentials in patterns of caregiving for this segment of the aging population. The analyses are based on the latest wave (Wave 7) of the Hispanic Established Population for Epidemiologic Studies of the Elderly or H-EPESE (2010/2011) a sample of older Mexican-origin adults and their family caregivers living in the southwestern U.S. We examine 629 child caregiver/parent care recipient dyads using bivariate statistics and multinomial logistic regression analyses. The results reveal that while grown children of Mexican-origin elders play a critical role in providing instrumental and financial supports to their aging parents, the burden that the children of foreign-born parents bear is greater. Despite higher rates of disability, Mexican-born elders are more dependent on a child for help and far less likely to call upon other family members, relatives and community based-providers for help than the U.S. born. Given the recent and future growth of older Latinos, intervention strategies will need to focus on nativity status and acculturative processes in the context of caregiving and caregiver burden.