Patterns of Home and Community Based Service Use by Beneficiaries Enrolled in the Pennsylvania Medicaid Aging Waiver

Factors Associated With Intended Utilization of Home-Based Long-Term Care Among Older Adults in China: The Moderating Effect of Community Support

OBJECTIVES

Guided by Andersen's behavioral model, the objectives of this study were to (a) examine the associations between individual factors and the intended utilization of home-based long-term care (LTC) services among older adults in China and (b) explore the influence of community support, if any, on these associations.

METHODS

Using a multistage random sampling approach, we recruited 1,064 older adults in Chengdu, China. Hierarchical regression was employed to investigate the direct effects of individual predictors and community support on the intended use of home-based LTC services. The moderating effect of community support was examined using the Hayes Process.

RESULTS

Two predisposing (i.e., being old and unmarried), 4 enabling (i.e., living alone, having fewer children, and receiving less family and peer support), and 6 need factors (i.e., having more chronic illnesses; decreased performance in instrumental activities of daily living; higher levels of depression, anxiety, loneliness; and a lower self-image of aging), and low community support were significantly associated with increased intended utilization of home-based LTC. In addition, community support moderated the effects of family support (B = -0.20, p < .001), peer support (B = -0.20, p < .001), self-image of aging (B = -0.39, p < .001), depression (B = -0.34, p < .001), and loneliness (B = -0.48, p < .001) on the intended utilization of home-based LTC services.

DISCUSSION

Policy-makers and practitioners should consider delivering tailored services for older adults and involve the community in the context of enhancing home-based LTC services.

Factors Associated with the Utilization of Home and Community-Based Services (HCBS) Among Older Adults: A Systematic Review of the Last Decade

Home and community-based services (HCBS) for older adults have been promoted worldwide to address the growing problems of aging. This systematic review included 59 studies published from 2013 to 2023 to explore factors influencing the utilization of HCBS among older adults. The review identified 15 common factors grouped into four levels of influence: individual, inter-relationship, community, and social contextual levels. The findings suggest that HCBS utilization is a dynamic process influenced by multiple factors at different levels. Gerontological social work should incorporate ecological thinking to improve practice and strengthen caregiver-recipient relationships.

Health Care Expenses and Financial Hardship Among Medicare Beneficiaries With Functional Disability

Importance

Medicare beneficiaries with functional disabilities often require more medical care, leading to substantial financial hardship. However, the precise magnitude and sources of this hardship remain unknown.

Objectives

To quantify the financial burden from health care expenses by functional disability levels among Medicare beneficiaries.

Design, Setting, and Participants

This cross-sectional study used data, including demographic and socioeconomic characteristics, health status, and health care use, from a nationally representative sample of Medicare beneficiaries from the 2013 to 2021 Medical Expenditure Panel Survey. Functional disability was measured using 6 questions and categorized into 3 levels: none (no difficulties), moderate (1-2 difficulties), and severe (≥3 difficulties). Data were analyzed from December 2023 to March 2024.

Main Outcomes and Measures

Financial hardship from health care expenses was assessed using objective measures (annual out-of-pocket spending, high financial burden [out-of-pocket spending exceeding 20% of income], and catastrophic financial burden [out-of-pocket spending exceeding 40% of income]) and subjective measures (difficulty paying medical bills and paying medical bills over time). We applied weights to produce results representative of national estimates.

Results

The sample included 31 952 Medicare beneficiaries (mean [SD] age, 71.1 [9.7] years; 54.6% female). In weighted analyses, severe functional disability was associated with a significantly higher financial burden from health care expenses, with out-of-pocket spending reaching $2137 (95% CI, $1943-$2330) annually. This exceeded out-of-pocket spending for those without functional disability by nearly $700 per year ($1468 [95% CI, $1311-$1625]) and for those with moderate functional disability by almost $500 per year ($1673 [95% CI, $1620-$1725]). The primary factors that played a role in this difference were home health care ($399 [95% CI, $145-$651]) and equipment and supplies ($304 [95% CI, $278-$330]). Beneficiaries with severe functional disability experienced significantly higher rates of both high and catastrophic financial burden than those without disability and those with moderate disability (13.2% [12.2%-14.1%] vs 9.1% [95% CI, 8.6%-9.5%] and 9.4% [95% CI, 9.1%-9.7%] for high financial burden, respectively, and 8.9% [95% CI, 7.8%-10.1%] vs 6.4% [95% CI, 6.1%-6.8%] and 6.0% [95% CI, 5.6%-6.4%] for catastrophic financial burden, respectively). Similar associations were observed in subjective financial hardship. For example, 11.8% (95% CI, 10.3%-13.3%) of those with severe functional disability experienced problems paying medical bills, compared with 7.7% (95% CI, 7.6%-7.9%) and 9.3% (95% CI, 9.0%-9.6%) of those without functional disability and those with moderate functional disability, respectively. Notably, there were no significant differences in financial hardship among those with Medicaid based on functional disability levels.

Conclusions and Relevance

In this cross-sectional study of Medicare beneficiaries, those with severe functional disability levels experienced a disproportionate burden from health care costs. However, Medicaid played a pivotal role in reducing the financial strain. Policymakers should explore interventions that effectively relieve the financial burden of health care in this vulnerable population.

Unaddressed functional difficulty and care support among White, Black, and Hispanic older adults in the last decade

Unaddressed functional difficulties contribute to disparities in healthy aging. While the Affordable Care Act (ACA) is believed to have reshaped long-term care, little is known how it has collectively altered the prevalence of older adults with functional difficulties and their use of family and formal care. This study uses nationally representative data from the Health and Retirement Study (2008 - 2018) to describe racial-ethnic differences in prevalence of community-dwelling older adults who had difficulty with, but lacked assistance for self-care, mobility, and household activities before and after the ACA. Individuals with functional difficulties accounted for about a third of Black and Hispanic, compared to one-fifth of White people. Prevalence of Black and Hispanic people with functional difficulties lacking corresponding care support was consistently 1.5 times higher than of White people. Racial-ethnic differences disappeared only for low-income households where unaddressed difficulties were uniformly high. While formal care quantity was similar, Black and Hispanic people with functional difficulties received nearly 50 percent more family care than White people. These gaps between White, Black, and Hispanic older adults were persistent over time. These findings suggest that racial-ethnic gaps in aging needs and supports remain despite major health care reforms in the past decade.

The Effects of Increasing State Minimum Wage on Family and Paid Caregiving

Older adults may receive either or a combination of unpaid family/friend and paid caregiving. The consumption of family/friend and paid caregiving may be sensitive to minimum wage policies. We used data (n = 11,698 unique respondents) from the Health and Retirement Study and a difference-in-differences design to evaluate associations between increases in state minimum wage between 2010 and 2014 and family/friend and paid caregiving consumed by adults age 65+ years. We also examined responses to increases in minimum wage for respondents with dementia or Medicaid beneficiaries. People living in states that increased their minimum wage did not consume substantially different hours of family/friend, paid, or any family/friend or paid caregiving. We did not observe differential responses between increases in minimum wage and hours of family/friend or paid caregiving among people with dementia or Medicaid beneficiaries. Increases in state minimum wage were not associated with changes in caregiving consumed by adults age 65+.

Applying Apriori algorithm to explore long-term care services usage status-Variables based on the combination of patients with dementia and their caregivers

Purpose

The aim of this study was to identify the combination of patients with dementia and their caregivers' characteristics associated with long-term care (LTC) services usage.

Patients and methods

A cross-sectional study was conducted with 475 patients with mild, moderate, and severe dementia at Changhua Christian Hospital, Taiwan. Eleven types of variables from patients with dementia, nine types of variables from patients' caregivers, and 15 types of LTC services were used for this study. The Apriori algorithm was employed to identify the attributes from the patients and their caregivers who used a particular LTC service from a comprehensive viewpoint.

Results

A total of 75 rules were generated by the Apriori algorithm with support of 2%, confidence of 80%, and lift >1. Among these rules, 25 rules belonged to home personal care services which were summarized further into four general rules for home personal care services. On the other hand, 50 rules belonged to assistive devices that were summarized further into 21 general rules based on their similarities. Patient's walking ability, patient's emotional liability, unemployed or retired caregivers, caregivers' feelings with either helplessness or hopelessness, and caregivers who cared for patients with dementia solely were found to be the critical variables to use home personal care services. In contrast, patient's walking ability, age, and severity as well as caregivers' age, mood, marital status, caregiving burden, and the patient being cared for mainly by a foreign care helper were found to be the critical variables to use assistive devices.

Conclusion

This study showed preliminary results on the LTC service usage from patients with dementia and their caregivers residing in the community. Understanding the patient-caregiver dyad's profile leads the service providers, policymakers, and the referral team to tailor service provisions better to meet the needs and identify the potential target groups. The findings in this study serve as references to reduce caregivers' burden as well as to improve the quality of care for patients with dementia.