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Stephens CE, Utz R, Tay D, Iacob E, Hollingshaus M, Goodwin R, Farrell TW, Bouldin E, Edelman L, Reinke LF, Smith K, Ellington L, Ornstein K. Dying with dementia in nursing homes: A population-based study of decedents and their families. J Am Geriatr Soc 2024; 72:1793-1801. [PMID: 38308399 DOI: 10.1111/jgs.18770] [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: 10/10/2023] [Revised: 12/15/2023] [Accepted: 12/27/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Families play a critical role in end-of-life (EOL) care for nursing home (NH) residents with dementia. Despite the important role of family, little is known about the availability and characteristics of families of persons with dementia who die in NHs. METHODS This is a retrospective cohort study of 18,339 individuals 65 years and older with dementia who died in a Utah NH between 1998 and 2016, linked to their first-degree family (FDF) members (n = 52,566; spouses = 11.3%; children = 58.3%; siblings = 30.3%). Descriptive statistics, chi-square tests, and t-tests were used to describe the study cohort and their FDF members and to compare sociodemographic and death characteristics of NH decedents with (n = 14,398; 78.5%) and without FDF (n = 3941; 21.5%). RESULTS Compared with NH decedents with FDF, NH decedents with dementia without FDF members were more likely to be older (mean age 86.5 vs 85.5), female (70.5% vs 59.3%), non-White/Hispanic (9.9% vs 3.2%), divorced/separated/widowed (84.4% vs 61.1%), less educated (<12th grade; 42.2% vs 33.7%), have Medicare and Medicaid (20.8% vs 12.5%), and die in a rural/frontier NH (25.0% vs 23.4%). NH decedents who did not have FDF were also more likely to die from cancer (4.2% vs 3.9%), chronic obstructive pulmonary disease (COPD; 3.9% vs 2.5%), and dementia (40.5% vs 38.4%) and were less likely to have 2+ inpatient hospitalizations at EOL (13.9% vs 16.2%), compared with NH decedents with FDF. CONCLUSIONS Findings highlight differences in social determinants of health (e.g., sex, race, marital status, education, insurance, rurality) between NH decedents with dementia who do and do not have FDF-factors that may influence equity in EOL care. Understanding the role of family availability and familial characteristics on EOL care outcomes for NH residents with dementia is an important next step to informing NH dementia care interventions and health policies.
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Affiliation(s)
| | - Rebecca Utz
- Sociology Department, University of Utah, Salt Lake City, Utah, USA
| | - Djin Tay
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Eli Iacob
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | | | - Rebecca Goodwin
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
- National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Timothy W Farrell
- Division of Geriatrics, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
- VA Salt Lake City Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, USA
| | - Erin Bouldin
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Linda Edelman
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Lynn F Reinke
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Ken Smith
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
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Scott MM, Ménard A, Sun AH, Murmann M, Ramzy A, Rasaputra P, Fleming M, Orosz Z, Huynh C, Welch V, Cooper-Reed A, Hsu AT. Building evidence to advance health equity: a systematic review on care-related outcomes for older, minoritised populations in long-term care homes. Age Ageing 2024; 53:afae059. [PMID: 38557665 PMCID: PMC10982852 DOI: 10.1093/ageing/afae059] [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: 04/14/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Advancing health equity requires more contextualised evidence. OBJECTIVES To synthesise published evidence using an existing framework on the origins of health disparities and determine care-related outcome disparities for residents of long-term care, comparing minoritised populations to the context-specific dominant population. DESIGN Systematic review. SUBJECTS Residents of 24-hour long-term care homes. METHODS The protocol was registered a priori with PROSPERO (CRD42021269489). Literature published between 1 January 2000 and 26 September 2021, was searched, including studies comparing baseline characteristics and outcomes in minoritised versus dominant populations. Dual screening, two-reviewer verification for extraction, and risk of bias assessments were conducted to ensure rigour. Studies were synthesized using a conceptual framework to contextualise evidence according to multi-level factors contributing to the development of care disparities. RESULTS Twenty-one of 34 included studies demonstrated disparities in care outcomes for minoritised groups compared to majority groups. Thirty-one studies observed differences in individual-level characteristics (e.g. age, education, underlying conditions) upon entry to homes, with several outcome disparities (e.g. restraint use, number of medications) present at baseline and remaining or worsening over time. Significant gaps in evidence were identified, particularly an absence of literature on provider information and evidence on the experience of intersecting minority identities that contribute to care-related outcome disparities in long-term care. CONCLUSION This review found differences in minoritised populations' care-related outcomes. The findings provide guidance for future health equity policy and research-supporting diverse and intersectional capacity building in long-term care.
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Affiliation(s)
- Mary M Scott
- The Public Health Agency of Canada, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alixe Ménard
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Annie H Sun
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Maya Murmann
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Amy Ramzy
- Bruyere Research Institute, Ottawa, ON, Canada
| | | | - Michelle Fleming
- Bruyere Research Institute, Ottawa, ON, Canada
- Ontario Centres for Learning, Research and Innovation in Long-Term Care, Ottawa, ON, Canada
| | - Zsófia Orosz
- Bruyere Research Institute, Ottawa, ON, Canada
- Ontario Centres for Learning, Research and Innovation in Long-Term Care, Ottawa, ON, Canada
| | - Chau Huynh
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Vivian Welch
- Bruyere Research Institute, Ottawa, ON, Canada
- The Campbell Collaboration, Philadelphia, PA, USA
| | | | - Amy T Hsu
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Ontario Centres for Learning, Research and Innovation in Long-Term Care, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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Hinton L, Tran D, Peak K, Meyer OL, Quiñones AR. Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review. Alzheimers Dement 2024; 20:3000-3020. [PMID: 38265164 PMCID: PMC11032576 DOI: 10.1002/alz.13612] [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: 03/28/2023] [Revised: 08/25/2023] [Accepted: 11/25/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers. METHODS We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings. RESULTS Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life. DISCUSSION Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.
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Affiliation(s)
- Ladson Hinton
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Duyen Tran
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Kate Peak
- Department of Family MedicineOregon Health & Science University (OHSU)PortlandOregonUSA
| | - Oanh L. Meyer
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Ana R. Quiñones
- Department of Family MedicineOregon Health & Science University (OHSU)PortlandOregonUSA
- OHSU‐PSU School of Public HealthOregon Health & Science UniversityPortlandOregonUSA
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Carpenter JG, Murthi J, Langford M, Lopez RP. A Nurse Practitioner-Driven Palliative and Supportive Care Service in Nursing Homes: Evaluation of a Quality Improvement Project. J Hosp Palliat Nurs 2024:00129191-990000000-00128. [PMID: 38529958 DOI: 10.1097/njh.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
This article describes a quality improvement project implemented by a national postacute long-term care organization aimed at enhancing the provision of palliative care to nursing home residents. The project focused on improving advance care planning, end-of-life care, symptom management, and care of people living with serious illness. Both generalist and specialist palliative care training were provided to nurse practitioners in addition to implementing a system to identify residents most likely to benefit from a palliative approach to care. To evaluate the nurse practitioner experiences of the program, survey data were collected from nurse practitioners (N = 7) involved in the project at 5 months after implementation. Nurse practitioners reported the program was well received by nursing home staff, families, and residents. Most nurse practitioners felt more confident managing residents' symptoms and complex care needs; however, some reported needing additional resources for palliative care delivery. Most common symptoms that were managed included pain, delirium, and dyspnea; most common diagnoses cared for were dementia and chronic organ failure (eg, cardiac, lung, renal, and neurological diseases). In the next steps, the project will be expanded throughout the organization, and person- and family-centered outcomes will be evaluated.
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Gaviola MA, Omura M, Inder KJ, Johnson A. Caring for people with dementia from culturally and linguistically diverse backgrounds in nursing homes: A scoping review. Int J Nurs Stud 2024; 151:104674. [PMID: 38215689 DOI: 10.1016/j.ijnurstu.2023.104674] [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: 07/12/2023] [Revised: 12/05/2023] [Accepted: 12/09/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND With continued increase in global migration, older people population in most countries is culturally diverse. Despite lesser preference for nursing home placement, people with dementia from culturally diverse backgrounds with higher needs and acuity do access nursing homes, however, little is known about care provision. OBJECTIVE The aims of this review were to map and synthesise available literature on care provision amongst people with dementia from culturally and linguistically diverse backgrounds in nursing homes and identify literature gaps that could inform future research. DESIGN A scoping review was conducted guided by the six-step scoping review methodology of Levac and colleagues. METHODS A literature search was conducted from August to September 2022 and updated in June 2023 using six databases: Medline, CINAHL, Embase, Cochrane Library, PsycINFO, and Scopus. Screening of articles, data extraction, and quality appraisal was performed independently by two authors. Articles included were primary empirical studies that explored care provision to people with dementia from culturally and linguistically diverse backgrounds living in nursing homes. Critical appraisal was conducted using the Joanna Briggs Institute Critical Appraisal Tool. Data were analysed using thematic analysis. Results were presented in a table and narrative format. RESULTS Of the 1149 articles identified, 25 were included. A majority of the articles were qualitative (n = 17) and conducted in Western countries such as those in Europe (n = 11), as well as Australia (n = 5) and the United States (n = 4). Data analysis led to the development of three themes: (1) maintaining a sense of home; (2) fostering communication and interaction; (3) barriers and facilitators to providing care. Most articles did not specify the model underpinning the approaches to care provision. CONCLUSIONS Care provision for people with dementia from culturally and linguistically diverse backgrounds living in nursing homes entails an environment which enables them to live up to the standards of what "home" means to them, communicate their needs, and engage in meaningful interactions. Predominant barriers to care provision relate to language and the facility's resources and capacity to deliver culture-specific care. Methodological quality of the studies that explored care provision for people with dementia from culturally and linguistically diverse backgrounds in the nursing home context is mostly limited. To strengthen the evidence base, there is a need for more rigorous research that informs care provision approaches and development of an inclusive model of culturally appropriate care to people with dementia from culturally diverse backgrounds in the nursing home context. TWEETABLE ABSTRACT A scoping review synthesised evidence on care provision amongst people with dementia from CALD backgrounds in nursing homes.
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Affiliation(s)
- Minah Amor Gaviola
- School of Nursing and Midwifery, The University of Newcastle, NSW, Australia.
| | - Mieko Omura
- School of Nursing and Midwifery, The University of Newcastle, NSW, Australia.
| | - Kerry Jill Inder
- School of Nursing and Midwifery, The University of Newcastle, NSW, Australia.
| | - Amanda Johnson
- School of Nursing and Midwifery, The University of Newcastle, NSW, Australia.
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Xu H, Bowblis JR, Becerra AZ, Intrator O. Developing a Machine Learning Risk-adjustment Method for Hospitalizations and Emergency Department Visits of Nursing Home Residents With Dementia. Med Care 2023; 61:619-626. [PMID: 37440719 PMCID: PMC10526959 DOI: 10.1097/mlr.0000000000001882] [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] [Indexed: 07/15/2023]
Abstract
BACKGROUND Long-stay nursing home (NH) residents with Alzheimer disease and related dementias (ADRD) are at high risk of hospital transfers. Machine learning might improve risk-adjustment methods for NHs. OBJECTIVES The objective of this study was to develop and compare NH risk-adjusted rates of hospitalizations and emergency department (ED) visits among long-stay residents with ADRD using Extreme Gradient Boosting (XGBoost) and logistic regression. RESEARCH DESIGN Secondary analysis of national Medicare claims and NH assessment data in 2012 Q3. Data were equally split into the training and test sets. Both XGBoost and logistic regression predicted any hospitalization and ED visit using 58 predictors. NH-level risk-adjusted rates from XGBoost and logistic regression were constructed and compared. Multivariate regressions examined NH and market factors associated with rates of hospitalization and ED visits. SUBJECTS Long-stay Medicare residents with ADRD (N=413,557) from 14,057 NHs. RESULTS A total of 8.1% and 8.9% residents experienced any hospitalization and ED visit in a quarter, respectively. XGBoost slightly outperformed logistic regression in area under the curve (0.88 vs. 0.86 for hospitalization; 0.85 vs. 0.83 for ED visit). NH-level risk-adjusted rates from XGBoost were slightly lower than logistic regression (hospitalization=8.3% and 8.4%; ED=8.9% and 9.0%, respectively), but were highly correlated. Facility and market factors associated with the XGBoost and logistic regression-adjusted hospitalization and ED rates were similar. NHs serving more residents with ADRD and having a higher registered nurse-to-total nursing staff ratio had lower rates. CONCLUSIONS XGBoost and logistic regression provide comparable estimates of risk-adjusted hospitalization and ED rates.
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Affiliation(s)
- Huiwen Xu
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - John R. Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, OH
- Scripps Gerontology Center, Miami University, Oxford, OH
| | - Adan Z. Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, NY
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Hunt LJ, Gan S, Smith AK, Aldridge MD, Boscardin WJ, Harrison KL, James JE, Lee AK, Yaffe K. Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia. J Palliat Med 2023; 26:1100-1108. [PMID: 37010377 PMCID: PMC10440673 DOI: 10.1089/jpm.2023.0011] [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: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Alexander K. Smith
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Krista L. Harrison
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer E. James
- Institute for Health and Aging, University of California, San Francisco, San Francisco, California, USA
| | - Alexandra K. Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, 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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Waymouth M, Siconolfi D, Friedman EM, Saliba D, Ahluwalia SC, Shih RA. Barriers and Facilitators to Home- and Community-Based Services Access for Persons With Dementia and Their Caregivers. J Gerontol B Psychol Sci Soc Sci 2023; 78:1085-1097. [PMID: 36896936 PMCID: PMC10214645 DOI: 10.1093/geronb/gbad039] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVES The United States has seen increasing shifts toward home- and community-based services (HCBS) in place of institutional care for long-term services and supports. However, research has neglected to assess whether these shifts have improved access to HCBS for persons with dementia. This paper identifies HCBS access barriers and facilitators, and discusses how barriers contribute to disparities for persons with dementia living in rural areas and exacerbate disparities for minoritized populations. METHODS We analyzed qualitative data from 35 in-depth interviews. Interviews were held with stakeholders in the HCBS ecosystem, including Medicaid administrators, advocates for persons with dementia and caregivers, and HCBS providers. RESULTS Barriers to HCBS access for persons with dementia range from community and infrastructure barriers (e.g., clinicians and cultural differences), to interpersonal and individual-level barriers (e.g., caregivers, awareness, and attitudes). These barriers affect the health and quality of life for persons with dementia and may affect whether individuals can remain in their home or community. Facilitators included a range of more comprehensive and dementia-attuned practices and services in health care, technology, recognition and support for family caregivers, and culturally competent and linguistically accessible education and services. DISCUSSION System refinements, such as incentivizing cognitive screening, can improve detection and increase access to HCBS. Disparities in HCBS access experienced by minoritized persons with dementia may be addressed through culturally competent awareness campaigns and policies that recognize the necessity of familial caregivers in supporting persons with dementia. These findings can inform efforts to ensure more equitable access to HCBS, improve dementia competence, and reduce disparities.
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Affiliation(s)
| | | | - Esther M Friedman
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Debra Saliba
- RAND Corporation, Santa Monica, California, USA
- UCLA Borun Center & Veterans Health Administration Geriatric Research, Education and Clinical Center, Los Angeles, California, USA
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10
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Hausmann LR, Lamorte C, Estock JL. Understanding the Context for Incorporating Equity into Quality Improvement Throughout a National Health Care System. Health Equity 2023; 7:312-320. [PMID: 37284535 PMCID: PMC10240324 DOI: 10.1089/heq.2023.0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 06/08/2023] Open
Abstract
Purpose Although health care systems aspire to deliver equitable care, practical tools that empower the health care workforce to weave equity throughout quality improvement (QI) processes are lacking. In this article, we report findings from context of use interviews that informed the development of a user-centered tool to support equity-focused QI. Methods Semistructured interviews were conducted from February to April of 2019. Participants included 14 medical center administrators, departmental or service line leaders, and clinical staff involved in direct patient care from three Veterans Affairs (VA) Medical Centers within a single region. Interviews covered existing practices for monitoring health care quality (i.e., priorities, tasks, workflow, and resources) and explored how equity data might fit into current processes. Themes extracted through rapid qualitative analysis were used to draft initial functional requirements for a tool to support equity-focused QI. Results Although the potential value of examining disparities in health care quality was clearly recognized, the data necessary for examining disparities were lacking for most quality measures. Interviewees also desired guidance on how inequities could be addressed through QI. The ways in which QI initiatives were selected, carried out, and supported also had important design implications for tools to support equity-focused QI. Discussion The themes identified in this work guided the development of a national VA Primary Care Equity Dashboard to support equity-focused QI within VA. Understanding the ways in which QI was carried out across multiple levels of the organization provided a successful foundation upon which to build functional tools to support thoughtful engagement around equity in clinical settings.
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Affiliation(s)
- Leslie R.M. Hausmann
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Jamie L. Estock
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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11
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Temkin‐Greener H, Yan D, Cai S. Post-acute care transitions and outcomes among Medicare beneficiaries with dementia: Associations with race/ethnicity and dual status. Health Serv Res 2023; 58:164-173. [PMID: 36054521 PMCID: PMC9836959 DOI: 10.1111/1475-6773.14059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To evaluate how post-acute care (PAC) transitions affect minority older adults with Alzheimer's disease or related dementia (ADRD), and the extent to which dual Medicare-Medicaid eligibility may attenuate or exacerbate disparities in PAC outcomes. We examined: (1) PAC referrals by race/ethnicity and dual status; (2) individual, hospital, and market-level factors associated with PAC; (3) the association between PAC and outcomes. DATA SOURCES/STUDY SETTING We used the following secondary data: Master Beneficiary Summary File (MBSF), Medicare Provider Analysis and Review (MedPAR), Minimum Data Set (MDS), Area Health Resource File (AHRF), hospital Provider of Services (POS) file, and the area deprivation index (ADI). STUDY DESIGN This observational study consisted of 619,262 community-residing Medicare fee-for-service (FFS) beneficiaries with ADRD who had a hospital stay in 2017. DATA COLLECTION/EXTRACTION METHODS PAC discharge was to skilled nursing facilities (SNF), home health care (HHC) agencies or home without services. Outcomes were 30-day readmission and death. Multinomial logistic regressions with hospital random effects (RE), stratified by dual eligibility, were fit. PRINCIPAL FINDINGS Dual-related differences were significantly larger than race/ethnicity differences in PAC transitions. For example, the difference in the probability of SNF transitions between White and Black patients was 3.2% and 6.8%-points for non-duals and duals, respectively. The difference between non-dual/dual White patients was 21.6% points, and among Black patients 18.0%-points. The adjusted risk of 30-day readmission was 5.6 percentage point higher among non-duals discharged to SNF, compared to home, but such risk among duals was not statistically significantly different. The adjusted probabilities of 30-day mortality were larger for duals and non-duals who transitioned to SNF, compared to those discharged home. CONCLUSIONS PAC referrals and the resulting outcomes for Medicare beneficiaries with ADRD are associated with multi-level variables that need to be incorporated in discharge decision making.
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Affiliation(s)
- Helena Temkin‐Greener
- Department of Public Health SciencesUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Di Yan
- Department of Public Health SciencesUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Shubing Cai
- Department of Public Health SciencesUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
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Yan D, Temkin-Greener H, Cai S. Did the COVID-19 Pandemic Affect the Use of Antipsychotics Among Nursing Home Residents With ADRD? Am J Geriatr Psychiatry 2023; 31:124-140. [PMID: 36272888 PMCID: PMC9514966 DOI: 10.1016/j.jagp.2022.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To examine whether and how the COVID-19 pandemic affected the use of antipsychotics among residents with Alzheimer's disease and related dementias in nursing homes. DESIGN Observational study based on the Minimum Data Set and Medicare claims. SETTING Medicare- and/or Medicaid-certified nursing homes. PARTICIPANTS Nursing home residents diagnosed with Alzheimer's disease and related dementias between 2017 and 2020. MEASUREMENTS The main outcome variable was any antipsychotic use during a quarter. The secondary outcome was certified nursing assistants' staffing hours per bed per day in a quarter. We categorized nursing homes into quartiles based on the distribution of nursing home racial and/or ethnic composition. To explore the relationship between the COVID-19 pandemic and the frequency of antipsychotic use, we estimated a linear probability model with robust standard errors, individual and facility random effects. We used a similar model for certified nursing assistant hours. RESULTS About 23.7% of residents with ADRD had antipsychotic uses during the study period. The frequency of antipsychotic use declined from 23.7%-23.1% between the first quarter of 2017 (2017Q1) and the first quarter of 2020 (2020Q1) but increased to 24.8% by the last quarter of 2020 (2020Q4). Residents in all four racial and/or ethnic groups experienced an increase in antipsychotic use during the COVID-19 pandemic, but the extent of the increase varied by race and/or ethnicity. For example, while residents in the very-high minority nursing homes experienced a greater increase in antipsychotic use than did the residents of other nursing homes at the beginning of the pandemic, the increasing trend during the pandemic was smaller in the very-high minority nursing homes compared to the low-minority nursing homes (0.2 percentage points less, p<0.001, based on heteroskedasticity-robust t statistics, t = 3.67, df = 8,155,219). On average, the certified nursing assistant hours decreased from 1.8-1.7 hours per bed per day between 2017Q1 and 2020Q1, and further decreased to 1.5 hours per bed per day by 2020Q4. There was also a decreasing trend in staffing hours across all racial and/or ethnic groups during the pandemic. CONCLUSIONS AND RELEVANCE The COVID-19 pandemic was associated with an increase in the use of antipsychotics among nursing home residents with Alzheimer's disease and related dementias and decreased staffing of certified nursing assistants, especially among nursing homes with a high minority penetration. Future research is needed to explore means for reducing antipsychotic use, particularly in homes with a high penetration of minority residents.
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Affiliation(s)
- Di Yan
- University of Rochester School of Medicine and Dentistry.
| | | | - Shubing Cai
- University of Rochester School of Medicine and Dentistry
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13
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Zhu Y, Olchanski N, Cohen JT, Freund KM, Faul JD, Fillit HM, Neumann PJ, Lin PJ. Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life. J Alzheimers Dis 2023; 96:1183-1193. [PMID: 37955089 PMCID: PMC10777481 DOI: 10.3233/jad-230692] [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] [Indexed: 11/14/2023]
Abstract
BACKGROUND Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. OBJECTIVE This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. METHODS This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. RESULTS Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. CONCLUSIONS Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.
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Affiliation(s)
- Yingying Zhu
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Natalia Olchanski
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Joshua T. Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Karen M. Freund
- Center for Health Equity Research, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Jessica D. Faul
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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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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Hill TE, Farrell DJ. COVID-19 Across the Landscape of Long-Term Care in Alameda County: Heterogeneity and Disparities. Gerontol Geriatr Med 2022; 8:23337214211073419. [PMID: 35071695 PMCID: PMC8777322 DOI: 10.1177/23337214211073419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 12/05/2022] Open
Abstract
Throughout the pandemic, public health and long-term care professionals in our urban California county have linked local and state COVID-19 data and performed observational exploratory analyses of the impacts among our diverse long-term care facilities (LTCFs). Case counts from LTCFs through March 2021 included 4309 (65%) in skilled nursing facilities (SNFs), 1667 (25%) in residential care facilities for the elderly (RCFEs), and 273 (4%) in continuing care retirement communities (CCRCs). These cases led to 582 COVID-19 resident deaths and 12 staff deaths based on death certificates. Data on decedents' age, race, education, and country of birth reflected a hierarchy of wealth and socioeconomic status from CCRCs to RCFEs to SNFs. Mortality rates within SNFs were higher for non-Whites than Whites. Staff accounted for 42% of LTCF-associated COVID-19 cases, and over 75% of these staff were unlicensed. For all COVID-19 deaths in our jurisdiction, both LTCF and community, 82% of decedents were age 65 or over. Taking a comprehensive, population-based approach across our heterogenous LTCF landscape, we found socioeconomic disparities within COVID-19 cases and deaths of residents and staff. An improved data infrastructure linking public health and delivery systems would advance our understanding and potentiate life-saving interventions within this vulnerable ecosystem.
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Affiliation(s)
- Terry E. Hill
- Alameda County Public Health
Department, Oakland, CA, USA
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16
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Rivera-Hernandez M, Kumar A, Roy I, Fashaw-Walters S, Baldwin JA. Quality of Care and Outcomes Among a Diverse Group of Long-Term Care Residents With Alzheimer's Disease and Related Dementias. J Aging Health 2021; 34:283-296. [PMID: 34634973 DOI: 10.1177/08982643211043319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
ObjectivesThis article assessed whether disparities among ADRD Medicare beneficiaries existed in five different long-stay quality measures. Methods: We linked individual-level data and facility-level characteristics. The main quality outcomes included whether residents: 1) were assessed/appropriately given the seasonal influenza vaccine; 2) received an antipsychotic medication; 3) experienced one/more falls with major injury; 4) were physically restrained; and 5) lost too much weight. Results: In 2016, there were 1,005,781 Medicare Advantage and fee-for-service long-term residents. About 78% were White, 13% Black, 2% Asian/Pacific Islander (Asian/PI), 6% Hispanic, and 0.4% American Indian/Alaska Native (AI/AN). Whites reported higher use of antipsychotic medications along with Hispanics and AI/AN (28%, 28%, and 27%, respectively). Similarly, Whites and AIs/ANs reported having one/more falls compared to the other groups (9% and 8%, respectively). Discussion: Efforts to understand disparities in access and quality of care among American Indians/Alaska Natives are needed, especially post-pandemic.
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Affiliation(s)
- Maricruz Rivera-Hernandez
- 6752Brown University School of Public Health, Providence, RI, USA.,174610Brown University School of Public Health, Providence, RI USA
| | - Amit Kumar
- 174610Brown University School of Public Health, Providence, RI USA.,3356Northern Arizona University, Flagstaff, AZ, USA.,174610Northern Arizona University, Flagstaff, AZ, USA
| | - Indrakshi Roy
- 174610Northern Arizona University, Flagstaff, AZ, USA
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Temkin-Greener H, Mao Y, McGarry B, Zimmerman S, Li Y. Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility. Med Care Res Rev 2021; 79:500-510. [PMID: 34623210 DOI: 10.1177/10775587211050189] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Assisted Living (AL) has become an important residential long-term care option in the United States, yet very little is known about the nature and quality of care received in this setting by racial/ethnic minorities or residents dually eligible for Medicare and Medicaid. Using calendar year 2018 Medicare data, we identified 255,564 fee-for-service Medicare beneficiaries age 55+ who resided in 24,108 ALs across the United States. We fit several logistic regression models with individual-level covariates and AL-level fixed effects, to examine the association between race/ethnicity and dual status with inpatient hospital admission, 30-day readmission, emergency room use, and nursing home placement. Significant variations in these measures were found both within and across ALs for racial/ethnic minority and dual residents. Our results suggest that disparities in outcomes are most significant by dual eligibility status rather than by race/ethnicity alone. These findings provide important implications for providers, policy makers, and researchers.
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Affiliation(s)
| | | | | | | | - Yue Li
- University of Rochester, NY, USA
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18
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Yan D, Wang S, Temkin-Greener H, Cai S. HCBS Service Spending and Nursing Home Placement for Patients With Alzheimer's Disease and Related Dementias: Does Race Matter? J Appl Gerontol 2021; 41:638-649. [PMID: 34615409 DOI: 10.1177/07334648211048187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES We examined the extent to which home and community-based services (HCBS) spending affected the likelihood of nursing home (NH) placement among black and white HCBS users with Alzheimer's disease and related dementias (ADRD). METHODS The study population included new HCBS users with ADRD between 2010 and 2013 (N = 1,046,200). RESULTS We found that a one hundred dollar increase in monthly HCBS spending was associated with a 0.3 percentage points decrease in the NH placement rate among Whites, but a 0.3 percentage points increase in the NH placement rate among Blacks. The overall NH placement rate was 68.2% and 56.7% for Whites and Blacks, respectively. DISCUSSION A higher HCBS spending was associated with a decreased likelihood of NH placements for Whites but not for Blacks. It is important to understand how states' HCBS expansion efforts influence Blacks and Whites with ADRD so that resources can be tailored to communities with different race-mix.
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Affiliation(s)
- Di Yan
- Department of Public Health Sciences, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sijiu Wang
- Department of Public Health Sciences, 123964University of Chicago, Chicago, IL, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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