An Assessment of State-Led Reform of Long-Term Services and Supports

Who Cares for Older Adults? A Cross-National Study of Care Sources for Older Adults With Functional Limitations and Associated Determinants

The study compared care source typologies for older adults in China and the United States. Data from the 2014 U.S. Health and Retirement Study and the 2013 China Health and Retirement Longitudinal Study were used. The respondents included community-dwelling older adults aged 65 years or older with at least one limitation in activities of daily living (ADLs) or instrumental ADLs (IADLs) (NChina = 2476, NUS = 2898). Respondents reported whether they received assistance from spouse, child/grandchild, relatives, others, and formal helpers. Latent class analysis and multinomial logistic regression were applied. Four classes were identified in China and the U.S, separately. In both countries, ADLs and IADLs were strong determinants of care source typologies. Care sources were more diverse and included formal assistance among older Americans. Older Chinese relied largely on their spouses and children/grandchildren for support. Policy efforts are needed to expand formal long-term services and supports, particularly in China.

Home- and Community-Based Provider Preparation for Pennsylvania's Managed Long-term Services and Supports

As Pennsylvania implements its managed long-term services and supports program, we explore how home- and community-based providers are preparing for and perceiving the transition through an online survey. We summarize responses and conduct chi-square analysis to measure differences between select provider groups. Despite high levels of uncertainty about program impact, over 84% of respondents plan to participate. We found that providers in the first implementation phase had more strategic and operational discussions with MCOs than the other two phases (p < .03). As program rollout continues, we anticipate changes in MCO-provider conversation frequency and topics based upon implementation zone.

Black-White Disparities in Moves to Assisted Living and Nursing Homes Among Older Medicare Beneficiaries

OBJECTIVES

Investigate black-white disparities in older adults' moves to assisted living and nursing homes and draw from the Andersen Healthcare Utilization Model to test explanations for any disparities.

METHODS

Data are from a nationally representative sample of older community-dwelling Medicare beneficiaries from the 2015 (N = 5,212) National Health and Aging Trends Study (NHATS). We use stepwise multinomial logistic regression to examine black-white disparities in moves out of community housing to assisted living or a nursing home over 2 years, before and after adjusting for predisposing (age, gender), enabling (income, housing tenure, Medicaid, living arrangement) and need (activities of daily living [ADL] limitation, physical capacity, self-rated health, and dementia) factors.

RESULTS

Black older adults are less likely to move to assisted living and are more likely to move to a nursing home compared to white older adults. Black-white disparities in moves to nursing homes are explained by black-white differences in enabling and need factors, whereas black-white disparities in moves to assisted living remain even after adjusting for enabling and need factors.

DISCUSSION

Unmeasured factors related to systemic racism (e.g., residential racial segregation, racial discrimination) and/or black-white differences in care preferences might further explain black-white disparities in moves to assisted living and warrant further investigation.

Family Caregiving in Serious Illness in the United States: Recommendations to Support an Invisible Workforce

Family caregivers provide the vast majority of care for individuals with serious illness living in the community but are not often viewed as full members of the healthcare team. Family caregivers are increasingly expected to acquire a sophisticated understanding of the care recipient's condition and new skills to execute complex medical or nursing tasks, often without adequate preparation and support, and with little choice in taking on the role. This review draws on peer-reviewed literature, government reports, and other publications to summarize the challenges faced by family caregivers of older adults in the context of serious illness and to identify opportunities to better integrate them into the healthcare workforce. We discuss promising approaches such as inclusion of family caregivers in consensus-based practice guidelines; the "no wrong door" function, directing consumers to needed resources, regardless of where initial contact is made; and caregiver-friendly workplace policies allowing flexible arrangements. We present specific recommendations focusing on research, clinical practice, and policy changes that promote family-centered care and improve outcomes for caregivers as well as persons with serious illness. J Am Geriatr Soc 67:S451-S456, 2019.

Identifying Predictors for Enhanced Outcomes for People With Intellectual and Developmental Disabilities

People with intellectual and developmental disabilities (IDD) often rely on Medicaid-funded services and supports to facilitate their daily living. The financial investment for these services is significant, yet little work has been conducted to understand how these investments affect life outcomes. This pilot study used a novel data integration approach to offer initial insights about how Medicaid expenditures relate to outcomes using Medicaid claims data, results of the National Core Indicators consumer survey, and data from the Supports Intensity Scale (SIS). Findings suggested that subpopulations of people with IDD who also had high behavioral needs or high medical needs had significantly higher expenditures than individuals with more typical SIS-assessed support needs. Regression analyses suggested mixed outcomes based on the factors we considered, including a finding that people with IDD who lived in sponsored residential care homes were more likely to engage in inclusive activities in the community than those who lived in larger congregate settings, or those who lived in a family home. Results of this pilot, when brought to scale, will be useful in examining the performance of state IDD service systems over time.

Calculating State-Level Estimates of Upcoming Older Adult Health Needs

OBJECTIVES

Census demographers have provided projections of the increased numbers of older adults in upcoming decades, but it is less clear whether they will also be any more or less healthy than current seniors. This is critical information for state planners, as the majority of older adults will need assistance with activities of daily living to remain in their homes. Previous longitudinal and cohort studies have yielded national estimates, but those more costly sources are generally beyond the resources of state public health agencies. We provide a more practicable model for assessing state-level changes in health-related quality of life (HRQOL) among middle-aged versus older adults as a guide to probable upcoming home- and community-based service needs.

METHODS

We used 2 sets of state Behavioral Risk Factor Surveillance System data 15 years apart to calculate and compare adjusted odds ratios of 8 poor HRQOL measures for middle-aged and older adults.

RESULTS

Compared with their peers only 15 years earlier, recent middle-aged adults had higher odds of poor outcomes across all HRQOL measures, whereas adults 65-74 years had higher odds of poor outcomes for far fewer of the measures. Among adults 75 years and older, odds were higher compared with 15 years ago for only 1 measure (multiple days of poor mental health).

CONCLUSIONS

Compared with older adults, the health profile of middle-aged adults in this state appears to have worsened much more rapidly in the past 15 years, indicating that these adults will have many more health-related needs when they become seniors. While this model is less sophisticated than others using longitudinal data, it provides the state-level data that are often more compelling to state policy makers.

Integrating Social Services and Home-Based Primary Care for High-Risk Patients

There is a consensus that our current hospital-intensive approach to care is deeply flawed. This review article describes the research evidence for developing a better system of care for high-cost, high-risk patients. It reviews the evidence that home-centered care and integration of health care with social services are the cornerstones of a more humane and efficient system. The article describes the strengths and weaknesses of research evaluating the effects of social services in addressing social determinants of health, and how social support is critical to successful acute care transition programs. It reviews the history of incorporating social services into care management, and the prospects that recent payment reforms and regulatory initiatives can succeed in stimulating the financial integration of social services into new care coordination initiatives. The article reviews the literature on home-based primary care for the chronically ill and disabled, and suggests that it is the emergence of this care modality that holds the greatest promise for delivery system reform. In the hope of stimulating further discussion and debate, the authors summarize existing viewpoints on how a home-centered system, which integrates social and medical services, might emerge in the next few years.

Factors Associated With Changes in Perceived Quality of Life Among Elderly Recipients of Long-Term Services and Supports

OBJECTIVES

Advance knowledge about changes in multiple dimensions of health related quality of life (HRQoL) among older adults receiving long-term services and supports (LTSS) over time and across settings.

DESIGN

A prospective, observational, longitudinal cohort design.

SETTING

Nursing homes (NHs), assisted living facilities (ALFs), community.

PARTICIPANTS

A total of 470 older adults who were first-time recipients of LTSS.

MEASUREMENT

Single-item quality-of-life measure assessed every 3 months over 2 years. HRQoL domains of emotional status, functional status, and social support were measured using standardized instruments.

RESULTS

Multivariable mixed effects model with time varying covariates revealed that quality-of-life ratings decreased over time (P < .001). Quality-of-life ratings were higher among enrollees with fewer depressive symptoms (P < .001), higher general physical function (P < .001), enhanced emotional well-being (P < .001), and greater social support (P = .004). Ratings also were higher among those with increased deficits in activities of daily living (P = .02). Ratings were highest among enrollees who received LTSS from ALFs, followed by NHs, then home and community-based services (H&CBS), but only findings between ALFs and H&CBS were statistically significant (P < .001). Finally, ratings tended to decrease over time among enrollees with greater cognitive impairment and increase over time among enrollees with less cognitive impairment (P < .001).

CONCLUSIONS

Findings advance knowledge regarding what is arguably the most important outcome of elderly LTSS recipients: quality of life. Understanding associations between multiple HRQoL domains and quality of life over time and directly from LTSS recipients represents a critical step in enhancing care processes and outcomes of this vulnerable population.