Adult day programs and their effects on individuals with dementia and their caregivers (ADAPT-DemCare): a realist synthesis to develop program theories on the how and why

BACKGROUND

Adult day programs aim to facilitate aging in place by supporting the health and well-being of persons with dementia and providing respite to their caregivers. However, studies on the effects of day programs are inconclusive, and we especially lack insights into the context conditions and mechanisms of day programs that may produce different outcomes for different groups of persons with dementia and their caregivers. Our objective was to conduct a realist review, synthesizing research on day programs to develop program theories explaining how and why day programs do or do not produce positive or negative outcomes for different groups of persons with dementia, and caregivers.

METHODS

We identified 14 literature reviews (including 329 references published between 1975 and 2021) on adult day programs. From this initial pool of studies, we will include those that focused on day program attendees with dementia or meaningful cognitive impairment, and/or their caregivers, and that report how day program contexts (C) and mechanisms (M) bring about outcomes (O) for attendees and caregivers. We will extract CMO statements (i.e., narratives that explain how and why day programs do or do not bring about certain outcomes for whom and under what circumstances). Using additional focused searches, citation mapping, citation tracking, and discussions with our researcher and expert team members, we will identify additional references. CMO statements will be synthesized, transformed into hypotheses, and linked and visualized to form program theories. Using focus groups and the James Lind Alliance Priority Setting Partnership method, we will discuss and prioritize our CMO statements and refine our program theories with 32 experts (older adults, caregivers, Alzheimer societies, caregiver organizations, day program staff and managers, and health system and policy decision makers).

DISCUSSION

By identifying essential elements and processes of day programs and related knowledge gaps, this study will generate much-needed knowledge to leverage the full potential of day programs so they can provide appropriate care, preventing premature institutionalization, and unnecessary acute and primary care use. This will ultimately improve the quality of life of persons with dementia and their caregivers, alleviate caregiver burden, and reduce social costs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42024504030.

Adult day services: a potential antidote to social isolation and loneliness in marginalized older adults

Loneliness and social isolation affect more than 1 in 4 community-dwelling older adults in the United States, who may also require long-term care support. Despite being seen as a solution to the long-term care crisis, most older adults prefer to age in place rather than using skilled nursing facilities. However, in-home care is unsustainable due to a shortage of direct care workers and may exacerbate social isolation by confining older adults to their homes. Adult Day Services (ADS) addresses both issues. ADS provides care to adults with physical, functional, and or cognitive limitations in non-residential, congregate, community-based settings. ADS also provides daily cognitive and physical stimulation, often with medical support, in a social and supported environment, centered around the needs and preferences of participants. Before the COVID-19 pandemic, nearly 5,000 ADS centers were widely available. However, with limited public support, the ADS industry has struggled as demand by the growing number of older adults and families need health and social support. The ADS industry must be recognized for its unique ability to buffer social isolation and loneliness in chronically ill older adults while serving as an effective platform for chronic disease management. This perspective piece highlights the critical role of ADS centers in reducing loneliness and social isolation and promoting healthy equity. We also explore the benefits of ADS, the financial, policy, and societal barriers to utilizing ADS, and the potential solutions to ensure its sustainability and growth.

EXploring Patterns of Use and Effects of Adult Day Programs to Improve Trajectories of Continuing Care (EXPEDITE): Protocol for a Retrospective Cohort Study

BACKGROUND

Adult day programs provide critical supports to older adults and their family or friend caregivers. High-quality care in the community for as long as possible and minimizing facility-based continuing care are key priorities of older adults, their caregivers, and health care systems. While most older adults in need of care live in the community, about 10% of newly admitted care home residents have relatively low care needs that could be met in the community with the right supports. However, research on the effects of day programs is inconsistent. The methodological quality of studies is poor, and we especially lack robust, longitudinal research.

OBJECTIVE

Our research objectives are to (1) compare patterns of day program use (including nonuse) by province (Alberta, British Columbia, and Manitoba) and time; (2) compare characteristics of older adults by day program use pattern (including nonuse), province, and time; and (3) assess effects of day programs on attendees, compared with a propensity score-matched cohort of older nonattendees in the community.

METHODS

In this population-based retrospective cohort study, we will use clinical and health administrative data of older adults (65+ years of age) who received publicly funded continuing care in the community in the Canadian provinces of Alberta, British Columbia, and Manitoba between January 1, 2012, and December 31, 2024. We will compare patterns of day program use between provinces and assess changes over time. We will then compare characteristics of older adults (eg, age, sex, physical or cognitive disability, area-based deprivation indices, and caregiver availability or distress) by pattern of day program use or nonuse, province, and time. Finally, we will create a propensity score-matched comparison group of older adults in the community, who have not attended a day program. Using time-to-event models and general estimating equations, we will assess whether day program attendees compared with nonattendees enter care homes later; use emergency, acute, or primary care less frequently; experience less cognitive and physical decline; and have better mental health.

RESULTS

This will be a 3-year study (July 1, 2024, to June 30, 2027). We received ethics approvals from the relevant ethics boards. Starting on July 1, 2024, we will work with the 3 provincial health systems on data access and linkage, and we expect data analyses to start in early 2025.

CONCLUSIONS

This study will generate robust Canadian evidence on the question whether day programs have positive, negative, or no effects on various older adult and caregiver outcomes. This will be a prerequisite to improving the quality of care provided to older adults in day programs, ultimately improving the quality of life of older adults and their caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06440447; https://clinicaltrials.gov/study/NCT06440447.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/60896.

Dementia-Related Disparities in Adult Day Centers: Results of a Bivariate Analysis

PURPOSE

Adult day services (ADS) are a valuable resource for people living with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD) and serve a large population of late-life immigrants, often with limited English proficiency (LEP). This secondary data analysis examined potential disparities in diagnosis, dementia severity, medical complexity, and dementia-related behavioral problems in persons with AD/ADRD with LEP within the ADS setting.

METHOD

The current study used data from TurboTAR, the electronic health record for ADS in California. Bivariate analyses were conducted to examine differences in clinical management for those with and without LEP.

RESULTS

Of 3,053 participants included in the study, 42.3% had LEP. Participants with LEP had higher rates of emergency department use and medication mismanagement. However, due to non-standard data collection, there was a significant amount of missing data on language preference (38.1%) and race/ethnicity (46.5%). Although these findings suggest LEP may play a role in the clinical management of persons with AD/ADRD in ADS, missing data caused by lack of standardized collection compromise the results.

CONCLUSION

It is essential to improve data collection practices in ADS on language, race, and ethnicity to help identify health disparities and promote equitable care for marginalized older adults. [Journal of Gerontological Nursing, 50(4), 42-47.].

Using mHealth to Improve Communication in Adult Day Services Around the Needs of People With Dementia: Mixed Methods Assessment of Acceptability and Feasibility

BACKGROUND

Adult day services (ADS) provide community-based health care for older adults with complex chronic conditions but rely on outdated methods for communicating users' health information with providers. CareMOBI, a novel mobile health (mHealth) app, was developed to address the need for a technological platform to improve bidirectional information exchange and communication between the ADS setting and providers.

OBJECTIVE

This study aims to examine the feasibility and acceptability of CareMOBI in the ADS setting.

METHODS

A concurrent-triangulation mixed methods design was used, and participants were client-facing ADS staff members, including direct care workers (paid caregivers), nurses, and social workers. Interviews were conducted to describe barriers and facilitators to the adoption of the CareMOBI app. The acceptability of the app was measured using an adapted version of the Technology Acceptance Model questionnaire. Data were integrated into 4 themes as anchors of an informational matrix: ease of use, clinical value, fit within workflow, and likelihood of adoption.

RESULTS

A mix of ADS staff (N=22) participated in the study. Participants reported high levels of acceptability across the 4 domains. Qualitative findings corroborated the questionnaire results; participants viewed the app as useful and were likely to implement CareMOBI in their practice. However, participants expressed a need for proper training and technical support throughout the implementation process.

CONCLUSIONS

The CareMOBI app has the potential to improve care management in the ADS setting by promoting effective communication through an easy-to-use and portable method. While the integration of CareMOBI is acceptable and feasible, developing role-specific training modules and technical assistance programs is imperative for successful implementation within the ADS setting.

A mixed-methods examination of the acceptability of, CareMOBI, a dementia-focused mhealth app, among primary care providers

Background

CareMOBI (mhealth for Organization to Bolster Interconnectedness) is a user-centered mobile application that supports secure communication between adult day health centers, primary care providers, and family caregivers. The aim of this study was to examine the acceptability of CareMOBI in the primary care setting and identify factors contributing to the likelihood of adoption among primary care providers.

Methods

We used a mixed-methods concurrent triangulation design. We, first, collected quantitative data using the Technology Acceptance Model questionnaire. Follow-up interview questions allowed participants to elaborate on their experience interacting with CareMOBI. We developed an informational matrix based on major themes within the Technology Acceptance Model (ease of use, value in clinical care, fit within existing workflows, and likelihood of adoption) in which qualitative data were embedded and compared.

Results

Our sample included 10 primary care providers. Participants rated CareMOBI high in ease of use (M = 6.71 out of 7), value in clinical care (M = 6.79), and likelihood of adoption (M = 6.71). They found specific functions of CareMOBI helpful, including the summary of health progress and the patient profile. In contrast, participants reported the lowest score for the fit of CareMOBI within existing workflows (M = 5.52). Qualitative feedback attributed this score to concerns over the lack of interoperability between CareMOBI in its current form and electronic health record systems used in the primary care setting.

Conclusion

Providers found CareMOBI valuable and easy to use, and there was a high likelihood of eventual adoption. However, apprehensions regarding workflow and electronic health records integration arose, which the team will have to consider as they move forward to the next phase of the application's development.

Social Prescription Interventions Addressing Social Isolation and Loneliness in Older Adults: Meta-Review Integrating On-the-Ground Resources

BACKGROUND

Social prescription programs represent a viable solution to linking primary care patients to nonmedical community resources for improving patient well-being. However, their success depends on the integration of patient needs with local resources. This integration could be accelerated by digital tools that use expressive ontology to organize knowledge resources, thus enabling the seamless navigation of diverse community interventions and services tailored to the needs of individual users. This infrastructure bears particular relevance for older adults, who experience a range of social needs that impact their health, including social isolation and loneliness. An essential first step in enabling knowledge mobilization and the successful implementation of social prescription initiatives to meet the social needs of older adults is to incorporate the evidence-based academic literature on what works, with on-the-ground solutions in the community.

OBJECTIVE

This study aims to integrate scientific evidence with on-the-ground knowledge to build a comprehensive list of intervention terms and keywords related to reducing social isolation and loneliness in older adults.

METHODS

A meta-review was conducted using a search strategy combining terms related to older adult population, social isolation and loneliness, and study types relevant to reviews using 5 databases. Review extraction included intervention characteristics, outcomes (social [eg, loneliness, social isolation, and social support] or mental health [eg, psychological well-being, depression, and anxiety]), and effectiveness (reported as consistent, mixed, or not supported). Terms related to identified intervention types were extracted from the reviewed literature as well as descriptions of corresponding community services in Montréal, Canada, available from web-based regional, municipal, and community data sources.

RESULTS

The meta-review identified 11 intervention types addressing social isolation and loneliness in older adults by either increasing social interactions, providing instrumental support, promoting mental and physical well-being, or providing home and community care. Group-based social activities, support groups with educational elements, recreational activities, and training or use of information and communication technologies were the most effective in improving outcomes. Examples of most intervention types were found in community data sources. Terms derived from the literature that were the most commonly congruent with those describing existing community services were related to telehealth, recreational activities, and psychological therapy. However, several discrepancies were observed between review-based terms and those addressing the available services.

CONCLUSIONS

A range of interventions found to be effective at addressing social isolation and loneliness or their impact on mental health were identified from the literature, and many of these interventions were represented in services available to older residents in Montréal, Canada. However, different terms were occasionally used to describe or categorize similar services across data sources. Establishing an efficient means of identifying and structuring such sources is important to facilitate referrals and help-seeking behaviors of older adults and for strategic planning of resources.

"The Sun Came Up Because You Got Here…": A Qualitative Exploration of Person-Centered Care Strategies Used by Adult Day Care Centers to Manage Behavioral and Psychological Symptoms of Dementia

In order to reduce care partner strain and support aging in place for people living with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), adult day centers (ADCs) must manage behavioral and psychological symptoms of dementia (BPSD). The purpose of this paper is to identify person-centered care strategies used by center staff to manage BPSD. Six focus groups with center staff (n = 31) were conducted. Data were analyzed using directed content analysis guided by Kitwood's conceptual approach to cultivating personhood in dementia care. Themes were identified and organized within Kitwood's framework. The results demonstrate that staff incorporate evidence-based person-centered approaches to AD/ADRD care that align with Kitwood's principles of comfort, attachment, inclusion, and identity. Staff individualize their approach to people with AD/ADRD within a group setting. They monitor, engage, socially stimulate, and, when needed, de-stimulate them. Centers are flexible social environments with underrecognized expertise managing BPSD using person-centered approaches.

Adult Day Services, Health Equity for Older Adults With Complex Needs, and the COVID-19 Pandemic

Morbidity and mortality from COVID-19 have unduly affected older adults from racial and ethnic minority groups. In this article, we highlight the experiences and vulnerabilities of diverse older adults with complex health and social needs when their access to vital, but overlooked, community-based adult day service centers (ADSCs) was abruptly cut off during a pandemic. Pandemic-related ADSC closures left vulnerable older adults and their care partners without essential daily support and services, such as health monitoring and socialization. However, the magnitude of the impact of ADSC closures on well-being, particularly among members of racial/ethnic minority groups, has yet to be measured with any form of "big data" because large-scale, nationally representative data sets consisting of participant-level information and outcomes associated with ADSC participation do not yet exist. Unmet needs of older adults resulting from pandemic-related ADSC closures are underrecognized because of a lack of systematic data collection, undermining efforts to achieve health equity. We call on ADSCs to link rigorous collection of racial and ethnic data to quality measures of access to equitable "age-friendly" care as a means of better supporting diverse community-dwelling older adults beyond the COVID-19 pandemic. (Am J Public Health. 2022;112(10):1421-1428. https://doi.org/10.2105/AJPH.2022.306968).

Development of a Resocialization Scale for Chinese Older Adult Migrants

With a rapidly aging population in China, resocialization is a concern amidst an increasing influx of older adult migrants. The aim of the current study was to develop a resocialization assessment scale for older migrants within the Chinese context. The study was conducted in two phases. A literature review and qualitative interview were performed to generate a draft scale that was further examined through Delphi expert consultation. Participants comprised 509 older migrants selected for a questionnaire survey. Analysis identified 62 items across four factors: interpersonal relationships, behavioral patterns, cultural integration, and social roles. Reliability and validity of the resulting assessment scale were verified. The scale can be used to evaluate the degree of resocialization exhibited by older migrants in Chinese communities. [Research in Gerontological Nursing, 15(5), 245-253.].

Multimorbidity patterns in adult day health center clients with dementia: a latent class analysis

BACKGROUND

Persons living with dementia (PLWD) in adult day centers (ADCs) represent a complex and vulnerable population whose well-being is at risk based on numerous factors. Greater knowledge of the interaction between dementia, chronic conditions, and social determinants of health would enable ADCs to identify and target the use of their resources to better support clients in need of in-depth intervention. The purpose of this paper is to (a) classify PLWD in ADCs according to their level of medical complexity and (b) identify the demographic, functional, and clinical characteristics of those with the highest degree of medical complexity.

METHODS

This was a secondary data analysis of 3052 clients with a dementia diagnosis from 53 ADCs across the state of California between 2012 and 2019. The most common diagnosis codes were organized into 28 disease categories to enable a latent class analysis (LCA). Chi-square test, analysis of variance (ANOVA), and Kruskal-Wallis tests were conducted to examine differences among latent classes with respect to clinical and functional characteristics.

RESULTS

An optimal 4-class solution was chosen to reflect chronic conditions among PLWD: high medical complexity, moderate medical complexity, low medical complexity, and no medical complexity. Those in the high medical complexity were taking an average of 12.72 (+/- 6.52) medications and attending the ADC an average of 3.98 days (+/- 1.31) per week-values that exceeded any other class. They also experienced hospitalizations more than any other group (19.0%) and met requirements for the nursing facility level of care (77.4%). In addition, the group experienced the greatest frequency of bladder (57.5%) and bowel (15.7%) incontinence.

CONCLUSIONS

Our results illustrate a high degree of medical complexity among PLWD in ADCs. A majority of PLWD not only have multimorbidity but are socially disadvantaged. Our results demonstrate that a comprehensive multidisciplinary approach that involves community partners such as ADCs is critically needed that addresses functional decline, loneliness, social isolation, and multimorbidity which can negatively impact PLWD.

Adult Day Service Use Among Minority Older Adults: Facilitators, Barriers, and Outcomes From an Updated Integrative Literature Review Between 2010 to 2021

Adult day services (ADS) are one of the more popular long-term care options for racial and ethnic minority older Americans. Focusing on minority older adults, this study aims to (a) identify both the individual and structural/organizational levels factors associated with ADS use and to (b) examine ADS' effect on health and well-being. Using the integrative review approach of Whittemore and Knafl, we found 14 studies published between 2010 to 2021. Findings concluded that individual-level needs and enabling factors were associated with ADS use and outcomes among minority older adults centered mostly on quality of life. Organizational/structural characteristics of ADS were never empirically examined in relation to service use or health outcomes. Future research should move beyond the individual level to identify and address the impact of the institutional structure, culture and practice on access, quality, and use.

Implications of the COVID-19 Pandemic on Adult Day Services and the Families They Serve

The COVID-19 pandemic forced adult day services (ADS) to close and abruptly end in-person services to clients. To understand the effect of the pandemic on ADS, a 20-item survey was used to examine services provided, staffing, finances, and plans to reopen. Data came from 22 sites participating in the Adult Day Service Plus a national randomized controlled trial. Of the 22 ADS sites responding to the survey, most (86.4%, n = 19) closed due to COVID-19 with nearly half closing due to a state mandate (52.6%, n = 10). Most sites reported the need to furlough or terminate staff (63.6%, n = 14). Services that sites continued to provide included telephone support (n = 22, 100%), delivery of food (n = 8, 36.4%), medical check-ins (n = 9, 40.1%), and activity via Zoom or YouTube (n = 14, 63.6%). Most of these services were provided without reimbursement. Adult day services have considerable potential as a platform for service innovation in community-based services.

Variations Between Adult Day Services Centers in the United States by the Racial and Ethnic Case-Mix of Center Participants

This is the first nationally representative study to identify differences between adult day services centers, a unique home- and community-based service, by racial/ethnic case-mix: Centers were classified as having a majority of participants who were Hispanic, non-Hispanic Black, or non-Hispanic other race/ethnicities and non-Hispanic White. The associations between racial/ethnic case-mix and geographic and operational characteristics of centers and health and functioning needs of participants were assessed using multivariate regression analyses, using the 2014 National Study of Long-term Care Providers' survey of 2,432 centers. Half of all adult day centers predominantly served racial/ethnic minorities, which were more likely to be for-profit, had lower percentages of self-pay revenue, more commonly provided transportation services, and had higher percentages of participants with diabetes, compared with predominantly non-Hispanic White centers. Findings show differences by racial/ethnic case-mix, which are important when considering the long-term care needs of a diverse population of older adults.

WITHDRAWN: The effect of commercial health insurance and health policy incentives on health risk assessment of residents

Ahead of Print article withdrawn by publisher.

Immigrants and dementia: Literature update

The population of immigrants in the U.S. is increasing with older immigrants experiencing age-related decline more rapidly than the U.S.-born white population. Immigrants have a higher prevalence and risk of dementia, including undiagnosed dementia. Older immigrants face unique obstacles in terms of their cognitive health, including language barriers, economic constraints, depressive symptoms, social isolation, low acculturation to the U.S., stigma related to dementia, and lacking education about dementia. Nurses, including advanced practice registered nurses, are well-positioned to enhance immigrants' access to accurate information about dementia and to promote immigrants' timely diagnosis and treatment of dementia symptoms. Several interventions have been developed specifically for immigrant caregivers. Immigrant families need interventions that provide education about dementia, offer resources for caregivers nationally and locally, and are targeted towards specific ethnic groups.

"Advocating Every Single Day" so as Not to be Forgotten: Factors Supporting Resiliency in Adult Day Service Centers Amidst COVID-19-Related Closures

Adult day centers (ADCs) are nonresidential settings that support the health and social needs of vulnerable older adults. Due to ADCs' congregate nature and participants' compromised health status, many ADCs have been forced to close during the COVID-19 pandemic. It is unknown how closures have impacted service delivery at ADCs. Guided by the Resiliency Activation Framework, we (a) identified consequences resulting from closures of ADCs during the COVID-19 pandemic and (b) described factors that have enabled the ADC community to remain resilient in the wake of challenges brought on by the pandemic. We conducted 2 focus groups in California (n = 12), and individual interviews with ADC staff members (n = 8) in 7 other states. The results of a directed content analysis revealed perceived declines in physical, cognitive, and mental health of ADC users and increased caregiver strain. Access to human, social, economic, and political capital were essential for supporting ADCs in buffering the impacts of the pandemic on the older adults they serve but were not consistently available. Research is urgently needed that quantifies the impacts of the pandemic on ADC users and their caregivers to inform policy and advocacy efforts in the wake of the pandemic.

A Qualitative Analysis of the Delivery of Person-Centered Nutrition to Asian Americans With Dementia in the Adult Day Health Care Setting

Adult day service centers (ADSCs) provide community-based long-term care, including meals, to racially diverse older adults, 47% of whom have dementia and consequently experience elevated nutritional risk. We examine nutritional behaviors for Chinese and Vietnamese persons living with dementia (PLWD) in ADSCs and evaluate the extent to which ADSCs provide person-centered nutritional care. Multi-stakeholder interviews were conducted. Data were coded using Dedoose and analyzed using Braun and Clarke's six-step method. The Model for the Provision of Good Nutritional Care in Dementia guided analysis. Barriers to food intake included distracting meal environment, rigid mealtimes, and excessively restrictive diets. Conversely, peer relationships, culturally tailored meals and celebrations, and consistent staff assisting with feeding benefited PLWD. ADSCs can support healthy nutritional behaviors and quality of life among PLWD through person-centered nutritional care. To optimize nutritional services, further exploration is needed with respect to the ADSC environment, users' culture and ethnicity, and liberalized diets for PLWD.

An Adapted Conceptual Model Integrating Palliative Care in Serious Illness and Multiple Chronic Conditions

OBJECTIVE

Seriously ill adults with multiple chronic conditions (MCC) who receive palliative care may benefit from improved symptom burden, health care utilization and cost, caregiver stress, and quality of life. To guide research involving serious illness and MCC, palliative care can be integrated into a conceptual model to develop future research studies to improve care strategies and outcomes in this population.

METHODS

The adapted conceptual model was developed based on a thorough review of the literature, in which current evidence and conceptual models related to serious illness, MCC, and palliative care were appraised. Factors contributing to patients' needs, services received, and service-related variables were identified. Relevant patient outcomes and evidence gaps are also highlighted.

RESULTS

Fifty-eight articles were synthesized to inform the development of an adapted conceptual model including serious illness, MCC, and palliative care. Concepts were organized into 4 main conceptual groups, including Factors Affecting Needs (sociodemographic and social determinants of health), Factors Affecting Services Received (health system; research, evidence base, dissemination, and health policy; community resources), Service-Related Variables (patient visits, service mix, quality of care, patient information, experience), and Outcomes (symptom burden, quality of life, function, advance care planning, goal-concordant care, utilization, cost, death, site of death, satisfaction).

DISCUSSION

The adapted conceptual model integrates palliative care with serious illness and multiple chronic conditions. The model is intended to guide the development of research studies involving seriously ill adults with MCC and aid researchers in addressing relevant evidence gaps.

Enriching Nutrition Programs to Better Serve the Needs of a Diversifying Aging Population

Racial minorities experience a high burden of food insecurity relative to non-Hispanic whites. Government-subsidized nutrition programs can positively impact food insecurity and nutritional risk among older adults. Yet, in New York City, where nearly 60% of people over 65 years are non-white, older minorities participate in government nutrition programs at very low rates. In this commentary, we focus on 2 programs: the Child and Adult Care Food Program and Older Americans Act Nutrition Services Programs. We identify opportunities for strengthening these programs to improve their reach and engagement with diverse older adults in New York City and similarly diverse urban communities.

Using the Social Ecological Model to Identify Drivers of Nutrition Risk in Adult Day Settings Serving East Asian Older Adults

Adult day care (ADC) centers provide community-based care (including meals) to frail, ethnically diverse older adults, many of whom are at risk for malnutrition. To support the development of interventions to benefit ADC users, the authors aimed to identify barriers and facilitators of healthy nutrition among ADC users born in Vietnam and China. Semi-structured qualitative interviews were conducted among ADC stakeholders to identify barriers and facilitators. Data were analyzed using Braun and Clarke's six-step method and organized within the framework of the Social Ecological Model. Facilitators of good nutrition included adherence to traditional diet at the ADC center, peer networks, and access to ethnic grocers. Poor health, family dynamics, and loneliness all contributed to poor nutrition, as did the restrictive nature of nutrition programs serving ADC users in the United States. Individual, relationship, organizational, community, and policy level factors play a role in ADC users' nutritional status. Targeted nutrition interventions should leverage culturally congruent relationships between ADC users and staff and include advocacy for enhancement of federal programs to support this population. [Research in Gerontological Nursing, 13(3), 146-157.].

A Mixed-Methods Evaluation of a Nurse-Led Community-Based Health Home for Ethnically Diverse Older Adults With Multimorbidity in the Adult Day Health Setting

Multimorbidity affects 75% of older adults (aged 65 years and older) in the United States and increases risk of poor medical outcomes, especially among the poor and underserved. The creation of a Medicaid option allowing states to establish health homes under the Affordable Care Act was intended to enhance coordinated care for Medicaid beneficiaries with multimorbidity. The Community-Based Health Home (CBHH) model uses the infrastructure of the Adult Day Health Center (ADHC) to serve as a health home to improve outcomes for medically complex vulnerable adults. Between 2017 and 2018, we used a sequential explanatory mixed-methods approach to (a) quantitatively examine changes in depression, fall risk, loneliness, cognitive function, nutritional risk, pain classification, and health care utilization over the course of 12 months in the program and (b) qualitatively explore the perspectives of key stakeholders (registered nurse navigators, participants, ADHC administrators, and caregivers) to identify the most effective components of CBHH. Using data integration techniques, we identified components of CBHH that were most likely driving outcomes. After 12 months in CBHH, our racially diverse sample (N = 126), experienced statistically significant (p < .05) reductions in loneliness, depression, nutritional risk, poorly controlled pain, and emergency department utilization. Stakeholders who were interviewed (n = 40) attributed positive changes to early clinical intervention by the registered nurse navigators, communication with providers across settings, and a focus on social determinants of health, in conjunction with social stimulation and engagement provided by the ADHC. CBHH positions the ADHC as the locus of an effective health home site and is associated with favorable results. CBHH also demonstrates the unique capacity and skill of registered nurses in integrating health and social services across community settings. Continued exploration of CBHH among diverse populations with multimorbidity is warranted.

Racial Disparities in Nutritional Risk among Community-Dwelling Older Adults in Adult Day Health Care

Information regarding nutritional risk among users of American adult day health centers (ADHCs), 60% of whom are racial minorities, is scant. This study examined nutritional risk and associated factors in a diverse sample ADHC users aged 50+ using secondary cross-sectional analysis of data collected between 2013 and 2017. Risk was assessed using the DETERMINE checklist, and results were stratified by race. The majority of the sample (N = 188) was at moderate (45.2%) or high (38.5%) nutritional risk, with statistically significant racial differences. Blacks were at greater risk than any other group: 65% had high nutritional risk; 76.5% ate <5 servings of fruits, vegetables, or milk daily; 21% ate <2 meals daily, 48.5% reported involuntary weight loss/gain, and 41.2% had tooth loss/mouth pain. Older adults in ADHCs are at elevated risk of malnutrition, disproportionately so amongst blacks. Both routine nutrition screening and population-specific approaches are needed to attenuate risk.