End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

Admission and Discharge Practices Among Assisted Living Communities: The Role of State Regulations and Organizational Characteristics

BACKGROUND AND OBJECTIVES

A better understanding of factors associated with assisted living admission and discharge practices can help identify communities that are more likely to allow residents to age in place. This study examined how state regulations and assisted living organizational characteristics related to community admission and discharge practices for bathing, getting out of bed, and feeding.

RESEARCH DESIGN AND METHODS

Using data from a representative sample of 250 assisted living communities in seven states and a database of assisted living state regulations, we employed multilevel logistic regression models to examine regulatory and organizational correlates of assisted living community admission and discharge practices for 3 activities of daily living (bathing, getting out of bed, and feeding).

RESULTS

States' regulations were not associated with assisted living community admission and discharge practices. However, assisted living communities above the median in the number of personal care staff members per resident were 17% (95% confidence interval [CI]: 6.5%, 27.1%) more likely to admit residents who needed assistance with feeding and 25.4% (95% CI: -37.7, -13.2) less likely to discharge these residents. For-profit communities were more likely to admit residents with bathing and feeding limitations.

DISCUSSION AND IMPLICATIONS

Organizational characteristics (e.g., for-profit affiliation, staffing levels) may, in part, drive admission and discharge practices, especially related to different care needs. The ability to house residents with advanced care needs may be influenced more by the organizational resources available to care for these residents than by states' admission and discharge regulations.

Naming racism as a root cause of inequities in palliative care research: a scoping review

BACKGROUND

Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist.

OBJECTIVE

To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings.

METHODS

Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results.

RESULTS

We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common.

CONCLUSION

While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

Assisted living residents with dementia: Disparities in mental health services pre and during COVID-19

BACKGROUND

Little is known about mental health among Medicare beneficiaries with Alzheimer's disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL residents with ADRD, pre and during the COVID pandemic, focusing on race/ethnicity and Medicare/Medicaid dual status.

METHODS

A CY2018 cohort of AL residents with ADRD was identified. Outcome was any quarterly in-person or telemedicine mental health visit based on national CY2019-2020 Medicare claims. Key independent variables were individual race/ethnicity and dual status and the AL-level proportion of dual residents. We estimated a linear probability model with random effects and robust standard errors. Quarterly indicators captured service use before and after the onset of the pandemic.

RESULTS

The study included 102,758 fee-for-service Medicare beneficiaries with ADRD in 13,400 ALs. One in five residents had any mental health visits prior to the COVID-19 pandemic. Black residents, and those with dual Medicare/Medicaid eligibility, were significantly less likely to use mental health services prior to and during the pandemic. There were no significant differences in visits via telemedicine by race/ethnicity or individual dual status. Residents in AL communities with a higher proportion of duals had a lower likelihood of visits before and during the pandemic.

CONCLUSIONS/IMPLICATIONS

Mental health service use among AL residents with ADRD was low and declining prior to the pandemic. Telehealth allowed for mental health visits to continue during the pandemic, albeit at a lower level. Residents in ALs with a higher proportion of duals were less likely to have in-person or telehealth visits. The results suggest that some ALs may find it difficult to assure mental health service provision to this vulnerable population.

Home time and state regulations among Medicare beneficiaries in assisted living communities

BACKGROUND

Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed nurse staffing.

METHODS

Medicare beneficiaries who entered AL communities in 2018 were identified, and their home time in the year following admission was measured. Home time was calculated as the percentage of time spent at home per day being alive. Resident characteristics and state regulations in DCW staffing, DCW training, and licensed staffing were measured. We used a multivariate linear regression model with AL-level fixed effects to estimate the relationship between person-level characteristics and home time. Linear regression models adjusting for resident characteristics were used to estimate the association between state regulations and residents' home time.

RESULTS

The study sample included 59,831 new Medicare beneficiary residents in 12,143 ALs. In the year following AL admission, residents spent 94% (standard deviation = 14.6) of their time at home. Several resident characteristics were associated with lower home time: Medicare-Medicaid dual eligibility, having more chronic conditions, and specific chronic conditions, for example, dementia. In states with greater regulatory specificity for DCW training and staffing, and lower specificity for licensed staffing, residents had longer adjusted home time.

CONCLUSION/IMPLICATIONS

Home time varied substantially among AL residents depending on resident characteristics and state-level regulatory specificity. AL residents eligible for Medicare and Medicaid had substantially shorter home time than the Medicare-only residents, largely due to longer time spent in nursing homes. State AL regulatory specificity for DCWs and licensed staff also impacted AL residents' home time. These findings may guide AL operators and state legislators in efforts to improve this important quality of life metric.

Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents

BACKGROUND

Assisted living (AL) is an increasingly common, place of care for dying persons. However, it remains unclear to what extent residents are able to age in place or if AL represents an additional transition before death.

OBJECTIVES

Examine the sociodemographic characteristics, comorbidities, health care utilization, and end-of-life care pathways of AL residents before death.

RESEARCH DESIGN

A national cohort study of fee-for-service Medicare beneficiaries residing in large AL communities (25+ beds) during the month of January 2017 with 3 years of follow-up, using administrative claims data.

SUBJECTS

268,812 AL residents.

MEASURES

Sociodemographic characteristics, comorbidities, and health care utilization at the end of life.

RESULTS

Between 2017 and 2019, 35.1% of the study cohort died. Decedents were more likely than the overall AL population to be 85 years old or older (76.5% vs. 59.5%), and diagnosed with Alzheimer's disease and related dementia (70.3% vs. 51.6%). Most decedents (96.2%) had some presence in AL during the last year of life, but over 1 in 5 left AL before the last month of life. Among those in AL on day 30 before death, nearly half (46.4%) died in place without any health care transition, while 13.2% had 3 or more transfers before dying.

CONCLUSIONS

AL is an important place of care for dying persons, especially for those with dementia. These findings indicate a need to assess existing policies and processes guiding the care of the frail and vulnerable population of dying AL residents.

Feasibility of the Palliative Care Education in Assisted Living Intervention for Dementia Care Providers: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

Alzheimer's disease and related dementia (ADRD) is a major cause of death in the United States. While effective interventions have been developed to deliver palliative care to nursing home residents with ADRD, little work has identified effective interventions to reach assisted living (AL) residents with dementia.

RESEARCH DESIGN AND METHODS

One hundred and eighteen AL residents with dementia from 10 different ALs in Florida participated. A pilot study using a cluster randomized trial was conducted, with 6 sites randomized to receive a palliative care educational intervention for staff (N = 23) to deliver care to residents; 4 sites were usual care. The feasibility of the intervention was assessed by examining recruitment, retention, and treatment fidelity at 6 months. Cohen's d statistic was used to calculate facility-level treatment effect sizes on key outcomes (documentation of advance care planning [ACP] discussions, hospice admission, and documentation of pain screening).

RESULTS

The intervention proved feasible with high ratings of treatment fidelity. The intervention also demonstrated preliminary evidence for efficacy of the intervention, with effect sizes for the treatment group over 0.80 for increases in documentation of ACP discussions compared to the control group. Hospice admissions had a smaller effect size (0.16) and documentation of pain screenings had no effect.

DISCUSSION AND IMPLICATIONS

The pilot results suggest that the intervention shows promise as a resource for educating and empowering AL staff on implementing person-centered palliative care delivery to persons with dementia in AL. A larger, fully powered randomized trial is needed to test for its efficacy.

Turning It Over to God: African American Assisted Living Residents' End-of-Life Preferences and Advance Care Planning

OBJECTIVES

Assisted living (AL), a popular long-term care setting for older Americans, increasingly is a site for end-of-life care. Although most residents prefer AL to be their final home, relatively little is known about end-of-life preferences and advance care planning, especially among African American residents. Our research addresses this knowledge gap.

METHODS

Informed by grounded theory, we present an analysis of qualitative data collected over 2 years in a 100-bed AL community catering to African American residents. Data consisted of field notes from participant observation conducted during 310 site visits and 818 observation hours, in-depth interviews with 25 residents, and a review of their AL records.

RESULTS

Residents varied in their end-of-life preferences and advance care planning, but united in the belief that God was in control. We identified "Turning it over to God" as an explanatory framework for understanding how this group negotiated end-of-life preferences and advance care planning. Individual-level resident factors (e.g., age, pain, and function) and factors reflecting broader cultural and societal influences, including health literacy and care experiences, were influential.

DISCUSSION

Contradictions arose from turning it over to God, including those between care preferences, planning, and anticipated or actual end-of-life outcomes.

State Regulations and Assisted Living Residents' Potentially Burdensome Transitions at the End of Life

Background: Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end-of-life care reported by bereaved family members. We examined the association between state RC/AL regulations relevant to end-of-life care delivery and the likelihood of residents experiencing potentially burdensome transitions. Methods: Retrospective cohort study combining RC/AL registries of states' regulations with Medicare claims data for residents in large RC/ALs (i.e., 25+ beds) in the United States on the 120th day before death (N = 129,153), 2017-2019. Independent variables were state RC/AL regulations relevant to end-of-life care, including third-party services, staffing, and medication management. Analyses included: (1) separate logistic regression models for each RC/AL regulation, adjusting for sociodemographic covariates; (2) separate logistic regression models with a Medicare fee-for-service (FFS) subgroup to control for comorbidities, and (3) multivariable regression analysis, including all regulations in both the overall sample and the Medicare FFS subgroup. Results: We found a lack of associations between potentially burdensome transitions and regulations regarding third-party services and staffing. There were small associations found between regulations related to medication management (i.e., requiring regular medication reviews, permitting direct care workers for injections, requiring/not requiring licensed nursing staff for injections) and potentially burdensome transitions. Conclusions: In this cross-sectional study, the associations of RC/AL regulations with potentially burdensome transitions were either small or not statistically significant, calling for more studies to explain the wide variation observed in end-of-life outcomes among RC/AL residents.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

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.

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors

OBJECTIVES

Online reviews provided by users of assisted living communities may offer a unique source of heretofore unexamined data. We explored online reviews as a possible source of information about these communities and examined the association between the reviews and aspects of state regulations, while controlling for assisted living, county, and state market-level factors.

DESIGN

Cross-sectional, observational study.

SETTING AND PARTICIPANTS

Sample included 149,265 reviews for 8828 communities.

METHODS

Primary (eg, state regulations) and secondary (eg, Medicare Beneficiary Summary Files) data were used. County-level factors were derived from the Area Health Resource Files, and state-level factors from the integrated Public Use Microdata series. Information on state regulations was obtained from a previously compiled regulatory dataset. Average assisted living rating score, calculated as the mean of posted online reviews, was the outcome of interest, with a higher score indicating a more positive review. We used word cloud to visualize how often words appeared in 1-star and 5-star reviews. Logistic regression models were used to determine the association between online rating and a set of community, county, and state variables. Models were weighted by the number of reviews per assisted living bed.

RESULTS

Overall, 76% of communities had online reviews. We found lower odds of positive reviews in communities with greater proportions of Medicare/Medicaid residents [odds ratio (OR) = 0.986; P < .001], whereas communities located in micropolitan areas (compared with urban), and those in states with more direct care worker hours (per week per bed) had greater odds of high rating (OR = 1.722; P < .001 and OR = 1.018, P < .05, respectively).

CONCLUSIONS AND IMPLICATIONS

Online reviews are increasingly common, including in long-term care. These reviews are a promising source of information about important aspects of satisfaction, particularly in care settings that lack a public reporting infrastructure. We found several significant associations between online ratings and community-level factors, suggesting these reviews may be a valuable source of information to consumers and policy makers.

Are online reviews of assisted living communities associated with patient-centered outcomes?

BACKGROUND

Existing literature on online reviews of healthcare providers generally portrays online reviews as a useful way to disseminate information on quality. However, it remains unknown whether online reviews for assisted living (AL) communities reflect AL care quality. This study examined the association between AL online review ratings and residents' home time, a patient-centered outcome.

METHODS

Medicare beneficiaries who entered AL communities in 2018 were identified. The main outcome is resident home time in the year following AL admission, calculated as the percentage of time spent at home (i.e., not in institutional care setting) per day being alive. Additional outcomes are the percentage of time spent in emergency room, inpatient hospital, nursing home, and inpatient hospice. AL online Google reviews for 2013-2017 were linked to 2018-2019 Medicare data. AL average rating score (ranging 1-5) and rating status (no-rating, low-rating, and high-rating) were generated using Google reviews. Linear regression models and propensity score weighting were used to examine the association between online reviews and outcomes. The study sample included 59,831 residents in 12,143 ALs.

RESULTS

Residents were predominately older (average 81.2 years), non-Hispanic White (90.4%), and female (62.9%), with 17% being dually eligible for Medicare and Medicaid. From 2013 to 2017, ALs received an average rating of 4.1 on Google, with a standard deviation of 1.1. Each one-unit increase in the AL's average online rating was associated with an increase in residents' risk-adjusted home time by 0.33 percentage points (p < 0.001). Compared with residents in ALs without ratings, residents in high-rated ALs (average rating ≥4.4) had a 0.64 pp (p < 0.001) increase in home time.

CONCLUSIONS

Higher online rating scores were positively associated with residents' home time, while the absence of ratings was associated with reduced home time. Our results suggest that online reviews may be a quality signal with respect to home time.

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

OBJECTIVES

To examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations.

DESIGN

We conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary Files. Other data sources were the Area Health Resource Files, a previously compiled national AL directory, and the US census. Data on state AL regulations were available from a prior study.

SETTING AND PARTICIPANTS

Participants included administrators and DCWs working in assisted living communities serving Medicare beneficiary residents.

METHODS

We employed exploratory factor analysis, examined Pearson correlations, and obtained standardized Cronbach alphas to test the PSC instrument. We estimated linear regression models with the dependent variable being the proportion of positive PSC assessments, for each PSC domain, with SEs clustered at the AL level.

RESULTS

Surveys were completed by 714 administrators and DCWs in 257 ALs. The PSC instrument tested reliable and valid for AL communities. Administrators' and DCWs' perceptions of PSC differed significantly across almost all domains. A 1-unit increase in state regulatory specificity for DCW staffing was associated with a 4.13-percentage point (P < .05) increase in the PSC staffing domain. Associations with regulatory specificity in staff training were also found for other PSC domains.

CONCLUSIONS AND IMPLICATIONS

PSC is an important metric for assessing organizational performance. DCWs have significantly worse perceptions of PSC than do administrators, suggesting it is crucial to understand the source of these differing perceptions. Because state regulations relate to PSC, achieving a comprehensive focus on patient safety in AL may require regulatory action, particularly increasing specificity with regard to staffing and training.