A National Typology of Health Service Regulation in Assisted Living

BACKGROUND AND OBJECTIVES

State-regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents' outcomes across similarly regulated communities.

RESEARCH DESIGN AND METHODS

We used qualitative and quantitative methods to empirically develop and describe a typology of state AL regulations that captures inter- and intrastate variation. Based on the rules governing health services, we created regulatory specificity scores for 5 thematic dimensions: medication administration, third-party care, skilled nursing, medication review, and licensed nurse staffing. With these scores, we conducted a K-means cluster analysis to identify groups of AL license types. To differentiate the regulatory types, we calculated standardized mean differences across structure, process, outcome, and resident characteristics of the AL communities licensed under each type.

RESULTS

We identified 6 types of AL differentiated by the regulatory provisions governing health services: Housing, Holistic, Hybrid, Hospitality, Healthcare, and Health Support. The types align with previous work and reflect tangible differences in resident characteristics, health service structures, processes, and outcomes.

DISCUSSION AND IMPLICATIONS

This typology effectively captures differences across regulated dimensions and can inform and support quality of care. Researchers, policy-makers, and consumers may benefit from using this typology and acknowledging these differences in AL licensure when designing research studies, developing policies, and selecting an AL community.

Evaluating the Implementation Fidelity of a Pilot Pragmatic Randomized Clinical Trial Comparing Daily-Delivered Meals to Mailed Frozen Meals

In pragmatic clinical trials (PCTs), the intervention is carried out by participating sites instead of research staff. In this paper, we evaluate study sites' implementation adherence during a pilot PCT of home-delivered meals for older adults with dementia. Participants at three home-delivered meal programs were randomized to receive either (1) meals delivered daily or (2) frozen meals mailed every two weeks; participants' outcomes were tracked for six months. Using the adherence domains from the Framework for Implementation Fidelity, we identified six metrics to assess adherence, with a total possible adherence score ranging from 6 (low adherence) to 18 (high adherence); all three sites scored within the top quartile of adherence. Despite challenges to meal delivery during the COVID-19 pandemic, sites successfully implemented the intervention, justifying a follow-on PCT to test the comparative effectiveness of models of meal delivery on the time to nursing home placement for people living with dementia.

A protocol for stakeholder engagement in deliver-EE: A pragmatic randomized comparative effectiveness trial evaluating effects of meal delivery on the ability of homebound older adults to remain in the community

BACKGROUND

Few clinical trials include a detailed protocol for stakeholder engagement in the design and execution of the clinical trial. Deliver-EE is a pragmatic clinical trial to assess how different types of home-delivered meals can affect older adults' health and well-being. We present the protocol for stakeholder engagement in this national, multi-site trial and initial findings from our efforts.

METHODS

Twenty-nine participants were recruited to two stakeholder advisory panels. The "Lived Experience Perspectives" panel is defined as the clients, caregivers, and meal delivery drivers with first-hand knowledge and lived experiences with meal delivery. The "System Perspectives" panel is defined as representatives from the larger financial, clinical, regulatory, and operational environments in which meal delivery to homebound older adults operate. Together, these two groups holistically represent interested parties that coordinate the interdependent elements of meal delivery to homebound older adults in order to: 1) inform our understanding of what matters most to older adults, their families, and the larger health and social care systems; 2) provide strategies to overcome challenges conducting the study; 3) enhance dissemination and uptake of study findings; and 4) identify opportunities for future research.

RESULTS

Although stakeholder partners share a common goal of using home-delivered meals as a method to improve outcomes for homebound older adults, individuals have different goals for participating as advisors in this research.

CONCLUSIONS

Understanding what individual stakeholders hope to gain from their participation is critical in designing an effective engagement protocol and critical for meaningful and rigorous stakeholder engagement in clinical trials.

Do end-of-life outcomes differ by assisted living memory-care designation?

BACKGROUND

Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer's disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate aging/dying in place for this population. The objective of this paper is to examine if end-of-life outcomes (i.e., mortality, hospice use, and number of days receiving hospice in the last month of life) differ between residents with ADRD who moved to memory-care RC/AL, compared with residents with ADRD who moved to RC/AL without memory care (general RC/AL).

METHODS

Prospective cohort of 15,152 fee-for-service Medicare beneficiaries with ADRD who moved to large RC/AL (> = 25 beds) between 2016 and 2018. We used inverse probability treatment weighting to account for observable differences between memory-care and general RC/AL residents. Two-part models estimated the difference by memory care in the number of days receiving hospice care in the last months of life among RC/AL decedents.

RESULTS

The unadjusted mortality rates were 13.4% in general RC/AL and 15.8% in memory-care RC/AL with an adjusted difference of 1.3 percentage points higher mortality among memory-care RC/AL residents (p = 0.04). Hospice use was 8% and 10.6% among general and memory-care RC/AL residents, respectively, with an adjusted difference of 1.4 percentage points (p = 0.01) higher in memory care. Two-part models showed that decedents in memory-care RC/AL spent about 1.4 more days receiving hospice care in the last month of life (p = 0.02).

CONCLUSION

We find a higher mortality rate and higher rate of hospice use among memory-care RC/AL residents. These findings suggest that memory care may attract residents closer to the end of life and/or promote hospice use at the end of life.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma

Importance

Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown.

Objective

To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane Irma.

Design, Setting, and Participants

Retrospective cohort study using 2017 Medicare claims data. Participants were a cohort of Florida AL residents who were aged 65 years or older, enrolled in Medicare fee-for-service, and resided in 9-digit zip codes corresponding to US assisted living communities with 25 or more beds on September 10, 2017, the day of Hurricane Irma's landfall. Propensity score matching was used to match evacuated residents to those that sheltered-in-place based on resident and AL characteristics. Data were analyzed from September 2022 to February 2024.

Exposure

Whether the AL community evacuated or sheltered-in-place before Hurricane Irma made landfall.

Main Outcomes and Measures

Thirty- and 90-day emergency department visits, hospitalizations, mortality, and nursing home admissions.

Results

The study cohort included 25 130 Florida AL residents (mean [SD] age 81 [9] years); 3402 (13.5%) evacuated and 21 728 (86.5%) did not evacuate. The evacuated group had 2223 women (65.3%), and the group that sheltered-in-place had 14 556 women (67.0%). In the evacuated group, 42 residents (1.2%) were Black, 93 (2.7%) were Hispanic, and 3225 (94.8%) were White. In the group that sheltered in place, 490 residents (2.3%) were Black, 707 (3.3%) were Hispanic, and 20 212 (93.0%) were White. After 1:4 propensity score matching, when compared with sheltering-in-place, evacuation was associated with a 16% greater odds of emergency department visits (adjusted odds ratio [AOR], 1.16; 95% CI, 1.01-1.33; P = .04) and 51% greater odds of nursing home visits (AOR, 1.51; 95% CI, 1.14-2.00; P = .01) within 30 days of Hurricane Irma's landfall. Hospitalization and mortality did not vary significantly by evacuation status within 30 or 90 days after the landfall date.

Conclusions and Relevance

In this cohort study of Florida AL residents, there was an increased risk of nursing home and emergency department visits within 30 days of Hurricane Irma's landfall among residents from communities that evacuated before the storm when compared with residents from communities that sheltered-in-place. The stress and disruption caused by evacuation may yield poorer immediate health outcomes after a major storm for AL residents. Therefore, the potential benefits and harms of evacuating vs sheltering-in-place must be carefully considered when developing emergency planning and response.

Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation

OBJECTIVE

The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation. Setting: Inpatient hospital, nursing home, and home health services.

PARTICIPANTS

Average of n= 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge.

DESIGN

Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank.

MAIN MEASURES

The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge.

RESULTS

We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score (β = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score (β = - 0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors (β = - 0.37; 95% CI, -0.66 to -0.07).

CONCLUSION

In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.

Getting to the root: Examining within and between home health agency inequities in functional improvement

OBJECTIVE

To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs).

DATA SOURCES

2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data.

DATA COLLECTION/EXTRACTION METHODS

Not Applicable.

STUDY DESIGN

We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins.

PRINCIPAL FINDINGS

Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities.

CONCLUSIONS

Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.

Physician Antipsychotic Overprescribing Letters and Cognitive, Behavioral, and Physical Health Outcomes Among People With Dementia: A Secondary Analysis of a Randomized Clinical Trial

Importance

Antipsychotics, such as quetiapine, are frequently prescribed to people with dementia to address behavioral symptoms but can also cause harm in this population.

Objective

To determine whether warning letters to high prescribers of quetiapine can successfully reduce its use among patients with dementia and to investigate the impacts on patients' health outcomes.

Design, Setting, and Participants

This is a secondary analysis of a randomized clinical trial of overprescribing letters that began in April 2015 and included the highest-volume primary care physician (PCP) prescribers of quetiapine in original Medicare. Outcomes of patients with dementia were analyzed in repeated 90-day cross-sections through December 2018. Analyses were conducted from September 2021 to February 2024.

Interventions

PCPs were randomized to a placebo letter or 3 overprescribing warning letters stating that their prescribing of quetiapine was high and under review by Medicare.

Main Outcomes and Measures

The primary outcome of this analysis was patients' total quetiapine use in days per 90-day period (the original trial primary outcome was total quetiapine prescribing by study PCPs). Prespecified secondary outcomes included measures of cognitive function and behavioral symptoms from nursing home assessments, indicators of depression from screening questionnaires in assessments and diagnoses in claims, metabolic diagnoses derived from assessments and claims, indicators of use of the hospital and other health care services, and death. Outcomes were analyzed separately for patients living in nursing homes and in the community.

Results

Of the 5055 study PCPs, 2528 were randomized to the placebo letter, and 2527 were randomized to the 3 warning letters. A total of 84 881 patients with dementia living in nursing homes and 261 288 community-dwelling patients with dementia were attributed to these PCPs. There were 92 874 baseline patients (mean [SD] age, 81.5 [10.5] years; 64 242 female [69.2%]). The intervention reduced quetiapine use among both nursing home patients (adjusted difference, -0.7 days; 95% CI, -1.3 to -0.1 days; P = .02) and community-dwelling patients (adjusted difference, -1.5 days; 95% CI, -1.8 to -1.1 days; P < .001). There were no detected adverse effects on cognitive function (cognitive function scale adjusted difference, 0.01; 95% CI, -0.01 to 0.03; P = .19), behavioral symptoms (agitated or reactive behavior adjusted difference, -0.2%; 95% CI -1.2% to 0.8% percentage points; P = .72), depression, metabolic diagnoses, or more severe outcomes, including hospitalization and death.

Conclusions and Relevance

This study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia. This intervention and others like it may be useful for future efforts to promote guideline-concordant care.

Trial Registration

ClinicalTrials.gov Identifier: NCT05172687.

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.

VA social workers identify factors predictive of enrollment and variability in Veterans' access to aid and attendance benefits

The Aid and Attendance (A&A) benefit is a cash entitlement for Veterans who served in the U.S. military to obtain personal care services. Our objective was to identify factors contributing to variation in A&A enrollment across VA Medical Centers (VAMCs). We used VA data to calculate the enrollment rate among older Veterans receiving a VA pension or compensation in 2015, then purposefully sampled social work leaders at 15 VAMCs with the highest (n = 7) and lowest (n = 8) enrollment rates for interviews. All respondents viewed A&A as an important benefit. Participants at high-enrollment sites indicated strong working relationships with Veterans Benefits Administration (VBA) and Veterans Service Organizations (VSOs) with onsite presence and education about A&A facilitate access. Participants at low-enrollment sites indicated they desired education around A&A eligibility criteria and collaboration with VBA/VSOs. VA and non-VA social workers would benefit from education about VBA's benefits, and this requires collaboration with VBA representatives.

Supporting mealtime participation among people living with dementia at home: Challenges and strategies for caregivers

BACKGROUND AND OBJECTIVES

Approximately 60% of people living with dementia at home are unable to routinely participate in mealtime activities (e.g., eating, safe food preparation), warranting assistance to ensure people with dementia meet their health and nutritional needs. The purpose of this study was to characterize these barriers to mealtime participation and identify potential caregiver-led strategies to enhance mealtime activities.

RESEARCH DESIGN AND METHODS

We used a qualitative descriptive approach and obtained semi-structured interview data from (a) allied health professionals and (b) community-based nutrition program providers who frequently serve people with dementia. Interview data were examined by means of directed content analysis and framework methodology until data saturation was reached. Codes from our analysis were categorized according to constructs drawn from the Socio-Ecological Model for Developing and Implementing Comprehensive Dementia Care.

RESULTS

Data were obtained from 20 participants who attributed common mealtime participation barriers to: impairments in functional status, cognitive status deficits, a lack of caregiver knowledge and skills, and unsafe living conditions. Caregiver-led strategies to overcome these barriers included: reducing auditory and visual distractions, providing written cues to perform mealtime activities, eliminating clutter and fall risk hazards, and leveraging community-based nutrition program providers (e.g., home-delivered meal providers).

DISCUSSION AND IMPLICATIONS

People with dementia face several eating and mealtime participation obstacles. Caregiver-led strategies implemented by family, friends, or community-based nutrition program providers may enhance mealtime activities at home. Findings point to opportunities to develop decision-making tools and resources for caregivers to optimize the health and nutrition of people with dementia.

Home-Delivered Meals and Nursing Home Placement Among People With Self-Reported Dementia: A Pilot Pragmatic Clinical Trial

Importance

Home-delivered meals promote food security and independence among homebound older adults. However, it is unclear which of the 2 predominant modes of meal delivery, daily-delivered vs mailed (or drop-shipped) frozen meals, promotes community living for homebound older adults with dementia.

Objective

To assess the risk of nursing home admission within 6 months between homebound individuals receiving daily-delivered vs drop-shipped frozen meals.

Design, Setting, and Participants

This pilot, multisite, 2-arm, pragmatic clinical trial included older adults with self-reported dementia on waiting lists for meals at 3 Meals on Wheels (MOW) programs in Texas and Florida between April 7 and October 8, 2021, to assess time to nursing home placement.

Interventions

Participants were randomized to receive either meals delivered by an MOW driver or frozen meals that were mailed to participants' homes every 2 weeks. Participants received their assigned intervention for up to 6 months.

Main Outcomes and Measures

The primary study outcome was days from randomization to a Minimum Data Set nursing home admission assessment within 6 months. Feasibility of conducting this type of study was examined by tracking enrollment, examining baseline characteristics, monitoring participants' intervention fidelity, measuring the proportion of participants linked with Centers for Medicare & Medicaid Services (CMS) data, and analyzing the primary study outcome.

Results

Among 325 eligible participants who were randomized, 243 enrolled in the study (mean [SD] age, 81 [8.0] years; 152 (62.6%) were female): 128 to the daily-delivered meals group and 115 to the drop-shipped frozen meals group; 119 participants (49.0%) lived alone. Among the total participants enrolled, 227 (93.4%) were linked deterministically to their CMS data; probabilistic methods were used to link the remaining 16 participants (6.6%). At 6 months from randomization, 160 participants (65.8%) were still receiving meals, and 25 (10.1%; 95% CI, 6.3%-14.0%) were admitted to a nursing home. After adjusting for sex, race and ethnicity, age, program, and living arrangement and the use of death as a censoring event, the adjusted log hazard ratio of nursing home placement between daily-delivered and drop-shipped frozen meals was -0.67 (95% CI, -1.52 to 0.19).

Conclusions and Relevance

This pilot randomized clinical trial demonstrated the feasibility of enrolling participants with self-reported dementia on waiting lists at MOW programs, linking their data, and evaluating outcomes. While this pilot study was not powered to detect meaningful, statistically significant differences in nursing home placement, its feasibility and initial results warrant exploration in a follow-on, adequately powered trial.

Trial Registration

ClinicalTrials.gov Identifier: NCT04850781.

Partnering with social service staff to implement pragmatic clinical trials: an interim analysis of implementation strategies

BACKGROUND

With recent growth in the conduct of pragmatic clinical trials, the reliance on frontline staff to contribute to trial-related activities has grown as well. Active partnerships with staff members are often critical to pragmatic trial implementation, but rarely do research teams track and evaluate the specific "implementation strategies" used to support staff's involvement in trial procedures (e.g., participant recruitment). Accordingly, we adapted implementation science methodologies and conducted an interim analysis of the strategies deployed with social service staff involved in one multi-site pragmatic clinical trial.

METHODS

We used a naturalistic, observational study design to characterize strategies our research team deployed with staff during monthly, virtual meetings. Data were drawn from meeting notes and recordings from the trial's 4-month Preparation phase and 8-month Implementation phase. Strategies were mapped to the Expert Recommendations for Implementing Change taxonomy and categorized into nine implementation clusters. Survey data were also collected from staff to identify the most useful strategies the research team should deploy when onboarding new staff members in the trial's second year.

RESULTS

A total of 287 strategies were deployed. Strategies in the develop stakeholder interrelationships cluster predominated in both the Preparation (35%) and Implementation (31%) phases, followed by strategies in the use iterative and evaluative approaches cluster, though these were more prevalent during trial Preparation (24%) as compared to trial Implementation (18%). When surveyed on strategy usefulness, strategies in the provide interactive assistance, use financial approaches, and support staff clusters were most useful, per staff responses.

CONCLUSIONS

While strategies to develop stakeholder interrelationships were used most frequently during trial Preparation and Implementation, program staff perceived strategies that provided technical assistance, supported clinicians, and used financial approaches to be most useful and should be deployed when onboarding new staff members. Research teams are encouraged to adapt and apply implementation strategy tracking methods when partnering with social service staff and deploy practical strategies that support pragmatic trial success given staff needs and preferences.

TRIAL REGISTRATION

NCT05357261. May 2, 2022.

Implementation of the HOME core outcome set for clinical trials of atopic eczema-barriers and opportunities: the HOME IX meeting report

The Harmonising Outcome Measures for Eczema (HOME) initiative established a core outcome set (COS) for atopic eczema (AE) clinical trials in 2019. This set encompasses four core outcome domains and corresponding measurement instruments: clinical signs (EASI), patient-reported symptoms (POEM and NRS 11 point for worst itch over the last 24 h), quality of life (DLQI/CDLQI/IDQoLI), and long-term control (Recap or ADCT). Following its roadmap, the HOME initiative is now focused on supporting implementation of the COS. To identify barriers and facilitators to implementation of the COS, and to guide the effort to promote COS uptake, a virtual consensus meeting was held over 2 days (September 25-26, 2021) attended by 55 participants (26 healthcare professionals, 16 methodologists, 5 patients, 4 industry representatives, and 4 students). Implementation themes were identified by a pre-meeting survey distributed to HOME members, presentations, and whole-group discussion. Participants were divided into five multi-professional small groups which ranked their top 3 most important themes, followed by whole-group discussion and anonymous consensus voting (consensus criteria: < 30% disagreement). Three most important implementation themes were identified and agreed upon: (1) awareness and stakeholder engagement, (2) universal applicability of the COS, and (3) ensuring minimum administrative burden. Working groups to address these issues are now a priority for the HOME initiative. The results from this meeting will inform the development of a HOME Implementation Roadmap in an effort to support other COS groups planning for effective implementation of their core sets.

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method

OBJECTIVE

Present an updated approach to identifying Medicare beneficiaries residing in licensed assisted living (AL) settings in the United States.

DESIGN

Retrospective cohort study using a national list of licensed AL settings, US Postal Service (USPS) data, and enrollment, claims, and assessment data from the Centers for Medicare and Medicaid Services.

SETTING AND PARTICIPANTS

A total of 403,326 beneficiaries residing in 29,905 licensed AL settings.

METHODS

We identified every ZIP+4 code affiliated with each AL address. We then identified all of the Medicare beneficiaries with that ZIP+4 on January 1, 2019, and excluded beneficiaries in nursing homes and hospitals on that date. We identified beneficiaries who were "definitively" and "very likely AL residents" according to the number of addresses corresponding to the ZIP+4 in the USPS data, the capacity of the AL setting, and the presence of a claim or assessment indicating services were delivered in AL. We compared beneficiaries excluded during our new capacity restriction step (ie, "possibly neighbors") to those included as being "definitively" and "very likely AL residents" using standardized mean differences.

RESULTS

The cohort excluded (ie, "possibly neighbors") using our new step in the identification process appears to be younger and healthier than the cohorts we include as being "definitively" and "very likely AL residents." In addition, the cohort we identified through our added step of supplementing with claims and assessment data have similar demographics to the other cohorts we include, although they appear to be in poorer health.

CONCLUSIONS AND IMPLICATIONS

Leveraging licensed capacity information and supplementing with claims and assessment data produce greater confidence in the ability to accurately identify AL residents using ZIP+4 codes reported in Medicare administrative data.

A Bayesian MultiLayer Record Linkage Procedure to Analyze Post-Acute Care Recovery of Patients with Traumatic Brain Injury

Understanding associations between injury severity and postacute care recovery for patients with traumatic brain injury (TBI) is crucial to improving care. Estimating these associations requires information on patients' injury, demographics, and healthcare utilization, which are dispersed across multiple data sets. Because of privacy regulations, unique identifiers are not available to link records across these data sets. Record linkage methods identify records that represent the same patient across data sets in the absence of unique identifiers. With a large number of records, these methods may result in many false links. Health providers are a natural grouping scheme for patients, because only records that receive care from the same provider can represent the same patient. In some cases, providers are defined within each data set, but they are not uniquely identified across data sets. We propose a Bayesian record linkage procedure that simultaneously links providers and patients. The procedure improves the accuracy of the estimated links compared to current methods. We use this procedure to merge a trauma registry with Medicare claims to estimate the association between TBI patients' injury severity and postacute care recovery.

Hospice Aide Visits among Nursing Home Residents During the Early Months of the COVID-19 Pandemic

OBJECTIVE

Hospice aides are vital in delivering care to patients and family members at the end of life. The COVID-19 pandemic resulted in disruptions in hospice care delivery, especially in long-term care settings. We aim to provide a description of hospice aide visits among nursing home residents enrolled in hospice during the first 9 months of 2020, as compared with the same months in 2019.

DESIGN

Observational cohort study.

SETTING AND PARTICIPANTS

153,109 and 152,077 long-stay nursing home residents enrolled in hospice in 2019 and 2020, respectively.

METHODS

On a monthly basis, we reported estimated probabilities of not having visits from hospice aides and adjusted visit minutes among those who had hospice aide visits for the 2019 and 2020 cohort, respectively. The regression models accounted for resident sociodemographic and clinical characteristics and nursing home fixed effects. The analyses were conducted at the national and state level, separately.

RESULTS

More than half of residents did not have any visits from hospice aides in 2020 from April and onward. Among residents who had hospice aide visits, the 2020 cohort had reduced visits in March and onward, with the greatest difference being 155 minutes less in April (95% CI: -163.4, -146.5). State-level analyses suggested that multiple factors besides community spread or state policies might contribute to the reduced presence of hospice aides.

CONCLUSIONS AND IMPLICATIONS

Our findings highlight the toll of the pandemic on hospice care delivery in nursing homes and the need for hospice care to be better incorporated into emergency preparedness planning.

State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia

OBJECTIVES

More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia.

DESIGN

This was an observational study using 20% sample of national Medicare data in 2017.

SETTING AND PARTICIPANTS

The study cohort included Medicare beneficiaries with dementia aged 65 years or older who resided in larger (≥25-bed) ALs in 2017.

METHODS

The study outcome was the percentage of eligible AL person-months in which antipsychotics were prescribed for each state. We used a random intercept linear regression model to shrink estimates toward the overall mean use of antipsychotics addressing unstable estimates due to small sample sizes in some states.

RESULTS

A total of 20,867 AL residents with dementia were included in the analysis, contributing to 194,718 person-months of observation. On average, AL residents with dementia were prescribed antipsychotics during 12.6% of their person-months. This rate varied significantly by state, with a low of 7.8% (95% CI 5.9%-10.3%) for Hawaii to a high of 20.5% (95% CI 16.4%-25.3%) for Wyoming.

CONCLUSIONS AND IMPLICATIONS

We observed significant state variation in the prescribing of antipsychotics among AL residents with dementia using national data. These variations may reflect differences in state regulations regarding the care for AL residents with dementia and suggest the need for further investigation to ensure high quality of care.

The relationship between exposure to Hurricane Harvey and mortality among nursing home residents

BACKGROUND

Nursing home (NH) residents are vulnerable to mortality after natural disasters. We examined NH residents' excess all-cause mortality associated with Hurricane Harvey, a unique disaster with long-lasting flooding effects. We also explored how mortality differed between short-stay and long-stay residents and by chronic conditions.

METHODS

We conducted a retrospective observational study of Texas NH residents, comparing 30- and 90-day mortality among residents exposed to Hurricane Harvey in August 2017 to residents not exposed in the same location and time period during the previous 2 years. Data came from the Minimum Data Set Assessments and the Medicare Beneficiary Summary File. We used linear probability models to examine the association between hurricane exposure and mortality, adjusting for resident demographics, clinical acuity, and NH fixed effects. Models were stratified by short-stay and long-stay status. We also described differences in mortality by residents' chronic conditions.

RESULTS

In 2017, 18,479 Texas NH residents were exposed to Hurricane Harvey. Exposure to Hurricane Harvey was not significantly associated with 30-day mortality. However, 7.6% (95% CI: 7.2, 7.9) of long-stay residents died 90 days after exposure to Harvey, compared to 6.3% (95% CI: 6.0, 6.7) during 2015. Apparently, this effect was driven by chronic obstructive pulmonary disease (COPD) as approximately 9.2% of these residents died within 90 days after Harvey landing compared to 7.2% in 2015 (p < 0.01).

CONCLUSIONS

Hurricane exposure appears to have significant consequences for mortality among long-stay NH residents, which appear to materialize over the long-term (90 days post-hurricane in our study) and may not be apparent immediately (30 days post-hurricane in our study). NH residents with COPD may be particularly vulnerable to increased mortality risk following hurricane exposure. The results highlight the need to pay special attention to mortality risk in NH residents, particularly those with COPD, following hurricane exposure.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States

OBJECTIVES

Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities.

DESIGN

We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations.

SETTING AND PARTICIPANTS

AL regulations and licensed AL communities across all 50 states in 2018.

METHODS

We estimated the proportion of all licensed AL communities regulated by admission limitations and identified groups consisting of those that limit admission based on a health-related condition, specified behavior, mental health condition, and/or cognitive impairment as well as those that impose no limitations to admission. We also estimated the proportion of all licensed AL communities required to conduct assessments at time of admission.

RESULTS

The largest group of ALs (29% nationally) is governed by regulations limiting the admission of persons with a health condition. The next largest group of AL communities (23.6%) limit admissions based on health, specified behavior, mental health conditions, and cognitive impairment. In contrast, 11.1% of licensed AL communities have no regulations restricting admissions. We also found that more than 8 of every 10 licensed communities were required to have residents complete a health assessment at admission, but less than half were required to complete a cognitive assessment.

CONCLUSIONS AND IMPLICATIONS

The variation we observe implies that state agencies have created multiple licensure classifications that serve as a mechanism for sorting types of residents into settings based on their need (eg, health, mental health, cognitive). Although future research should investigate the implications of this regulatory diversity, the categories outlined here may be helpful to clinicians, consumers, and policy makers to better understand the options in their state and how various AL licensure classifications compare to one another.

Association of Medicaid Financing and Concentration of Assisted Living Residents Dually Eligible for Medicare and Medicaid

This cross-sectional study examines different levels of state Medicaid financing for assisted living and the association with the number of beneficiaries with dual Medicare and Medicaid eligibility who live in assisted living facilities.

Injury-related emergency department use among assisted living residents with Alzheimer's disease and related dementias

BACKGROUND

Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL.

METHODS

Using Medicare claims, we identified a cohort of fee-for-service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site-specific information on memory care designation (n = 116,754). Outcomes included all injury-related ED visits and injury-related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury-related ED visits.

RESULTS

The adjusted risk of injury-related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury-related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury-related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL.

CONCLUSIONS

Injury-related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD.

Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island

As health systems attempt to contain utilization and costs, care management programs are proliferating. However, there are mixed findings on their impact. In 2018, Rhode Island initiated a care management program for dually eligible Medicare and Medicaid beneficiaries at high risk of hospitalization or institutionalization. The objective of this study is to evaluate the association between health care utilization and costs and care management for dual-eligible participants (n = 169). The authors employed an interrupted time series analysis of administrative claims data using the Rhode Island All Payer Claims Database, which includes data from all major payers in the state, for 11 quarters (January 1, 2017 until September 1, 2019). On average, participants were younger (46.2% were 19-64 years of age vs. 41.9% of non-participants), female (71% vs. 62.6% of non-participants), and had a higher comorbidity burden (more commonly had anemia, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, ischemic heart disease, and stroke). Participation was associated with significantly fewer hospital admissions (118 fewer admissions per 1000 admissions per quarter; 95% confidence interval [CI] -11 to -22), and a reduction in Medicaid ($1841 less spent per quarter, 95% CI -2407 to -1275) and total ($2570 less spent per quarter; 95% CI -$4645 to -$495) costs. Participation was not significantly associated with a change in Emergency Department (ED) visits, preventable ED visits, Skilled Nursing Facility stays, or Medicare costs. These results suggest that targeted care management programs may provide dual-eligible beneficiaries with needed services while diverting inefficient health care utilization.

Medication Costs and Use of Older Americans in Assisted Living Settings: a Nationally Representative Cross-Sectional Study

BACKGROUND

Assisted-living (AL) settings are an important residential care option for old and disabled Americans, but there are no national data characterizing medication use in AL.

OBJECTIVE

To investigate medication costs and use of older adults living in the AL settings compared to those in the community, independent living, and nursing home settings.

DESIGN

2015 National Health and Aging Trends Study; nationally representative cross-sectional study.

PATICIPANTS

Respondents ≥ 65 years with Medicare Part D prescription drug coverage (n = 5980, representing 32.34 million older adults).

MEASURES

Total Part D medication costs; number of 30-day prescription fills; binary indicators for overall polypharmacy (≥ 5 and ≥ 10 concurrent medications), prescription fills of opioid and psychotropic medications including antipsychotics, benzodiazepines, gabapentinoids, antidepressants, and central nervous system-active (CNS-active) polypharmacy.

RESULTS

Adjusting for demographics, the annual medication costs among AL residents, at $3890, were twice as high as those of their community-dwelling counterparts ($1932; p < .01). All medication outcomes except opioids were higher for older adults in AL compared to community settings. While the adjusted number of 30-day prescription fills among AL residents was slightly lower than that of nursing home residents (89.5 vs. 106.2; p < .05), AL residents experienced equivalent rates of overall polypharmacy ≥ 10 medications (30.2% vs. 23.5%), antipsychotics (30.8% vs. 27.8%), benzodiazepines (30.7% vs. 32.6%), gabapentinoids (21.2% vs. 16.1%), and CNS-active polypharmacy (26.0% vs. 36.9%; p > .05 for all). Patterns of use across settings were consistent when limited to older adults with dementia.

CONCLUSIONS

Older Americans in AL experience a prescription medication burden similar to those in nursing homes. AL settings have an important opportunity to ensure their medication-related clinical services and supports match the needs of their residents.

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.

Health of the Food Environment Is Associated With Heart Failure Mortality in the United States

BACKGROUND

Food environment factors contribute to cardiovascular disease, but their effect on population-level heart failure (HF) mortality is unclear.

METHODS

We utilized the National Vital Statistics System and USDA Food Environment Atlas to collect HF mortality rates (MR) and 2 county food environment indices: (1) food insecurity percentage (FI%) and (2) food environment index (FEI), a scaled index (0-10, 10 best) incorporating FI% and access to healthy food. We used linear regression to estimate the association between food environment and HF MR Results: Mean county FI% and FEI were 13% and 7.8 in 2956 included counties. Counties with FI% above the national median had significantly higher HF MR (30.7 versus 26.7 per 100 000; P<0.001) compared with FI% below the national median. Counties with HF MR above the national median had higher FI%, lower FEI, lower density of grocery stores, poorer access to stores among older adults, and lower Supplemental Nutrition Assistance Program participation rate (P<0.001 for all). Lower county FI% (β=-1.3% per 1% decrease) and higher county FEI (β=-3.6% per 1-unit increase in FEI) were significantly associated with lower HF MR after adjustment for county demographic, socioeconomic, and health factors. This association was stronger for HF MR compared with non-HF cardiovascular disease MR and all-cause MR The relationship between food environment and HF MR was stronger in counties with the highest income inequity and poverty rate.

CONCLUSIONS

Healthier food environment is significantly associated with lower HF mortality at the county level. This reinforces the role of food security on cardiovascular outcomes.

Psychotropic medication prescribing in assisted living and nursing home residents with dementia after the National Partnership

BACKGROUND

The Centers for Medicare & Medicaid Services implemented the National Partnership to Improve Dementia Care in Nursing Homes (the Partnership) to decrease antipsychotic use and improve care for nursing home (NH) residents with dementia. We determined whether the extent of antipsychotic and other psychotropic medication prescribing in AL residents with dementia mirrored that of long-stay NH (LSNH) residents after the Partnership.

METHODS

Using a 20% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study including AL and LSNH residents with dementia. The monthly prevalence of psychotropic medication prescribing (antipsychotics, antidepressants, anxiolytics/sedative-hypnotics, anticonvulsants/mood stabilizers, benzodiazepines, and antidementia medications) was examined. We used an interrupted time-series analysis to compare medication prescribing before (July 1, 2010-March 31, 2012) and after (April 1, 2012-December 31, 2017) the Partnership in both settings.

RESULTS

We identified 107,931 beneficiaries with ≥1 month as an AL resident and 323,766 beneficiaries with ≥1 month as a LSNH resident with dementia, including 1,923,867 person-months and 4,984,405 person-months, respectively. Antipsychotic prescribing declined over the study period in both settings. After the launch of the Partnership, the rate of decline in antipsychotic prescribing slowed in AL residents with dementia (slope change = 0.03 [95% CLs: 0.02, 0.04]) while the rate of decline in antipsychotic prescribing increased in LSNH residents with dementia (slope change = -0.12 [95% CLs: -0.16, -0.08]). Antidepressants were the most prevalent medication prescribed, anticonvulsant/mood stabilizer prescribing increased, and anxiolytic/sedative-hypnotic and antidementia medication prescribing declined.

CONCLUSIONS

The federal Partnership to reduce antipsychotic prescribing in NH residents did not appear to affect antipsychotic prescribing in AL residents with dementia. Given the increase in the prescribing of mood stabilizers/anticonvulsants that occurred after the launch of the Partnership, monitoring may be warranted for all psychotropic medications in AL and NH settings.

Determinants of inter-organizational implementation success: A mixed-methods evaluation of Veteran Directed Care

BACKGROUND

Veteran Directed Care (VDC) aims to keep Veterans at risk for nursing home placement in their communities. VA medical centers (VAMCs) purchase VDC from third-party organizational providers who then partner with them during implementation. Experiences with VDC implementation have varied.

OBJECTIVES

We sought to identify conditions differentiating partnerships with higher enrollment (implementation success).

METHODS

We conducted a case-based study with: qualitative data on implementation determinants two and eight months after program start, directed content analysis to assign numerical scores (-2 strong barrier to +2 strong facilitator), and mathematical modeling using Coincidence Analysis (CNA) to identify key determinants of implementation success. Cases consisted of VAMCs and partnering non-VAMC organizations who started VDC during 2017 or 2018. The Consolidated Framework for Implementation Research (CFIR) guided analysis.

RESULTS

Eleven individual organizations within five partnerships constituted our sample. Two CFIR determinants- Networks & Communication and External Change Agent-uniquely and consistently identified implementation success. At an inter-organizational partnership level, Networks & Communications and External Change Agent +2 (i.e., present as strong facilitators) were both necessary and sufficient. At a within-organization level, Networks & Communication +2 was necessary but not sufficient for the non-VAMC providers, whereas External Change Agent +2 was necessary and sufficient for VAMCs.

CONCLUSION

Networks & Communication and External Change Agent played difference-making roles in inter-organizational implementation success, which differ by type of organization and level of analysis.

IMPLICATIONS

This multi-level approach identified crucial difference-making conditions for inter-organizational implementation success when putting a program into practice requires partnerships across multiple organizations.

Association Between State Regulations Supportive of Third-party Services and Likelihood of Assisted Living Residents in the US Dying in Place

Importance

Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place.

Objective

To examine the association between state regulations and the likelihood of assisted living residents dying in place. The study hypothesis was that regulations supporting third-party services, such as hospice, increase the likelihood of assisted living residents dying in place.

Design, Setting, and Participants

This retrospective cohort study combined data about assisted living residences in the US from state registries with an inventory of state regulations and administrative claims data. The study participants comprised 168 526 decedents who were Medicare beneficiaries, resided in 8315 large, assisted living residences (with ≥25 beds) across 301 hospital referral regions during the last 12 months of their lives, and died between 2017 and 2019. Descriptive analyses were performed at the state level, and 3-level multilevel models were estimated to examine the association between supportive third-party regulations and dying in place in assisted living residences. The data were analyzed from September 2021 to August 2022.

Exposures

Supportive (vs "silent," ie, not explicitly mentioned in regulatory texts) state regulations regarding hospice care, private care aides, and home health services, as applicable to licensed/registered assisted living residences across the US.

Main Outcomes and Measures

Presence in assisted living residences on the date of death.

Results

The median (IQR) age of the 168 526 decedents included in the study was 90 (84-94) years. Of these, 110 143 (65.4%) were female and 158 491 (94.0%) were non-Hispanic White. Substantial variation in the percentage of assisted living residents dying in place was evident across states, from 18.0% (New York) to 73.7% (Utah). Supportive hospice and home health regulations were associated with a higher odds of residents dying in place (adjusted odds ratio [AOR], 1.38; 95% CI, 1.24-1.54; P < .001; and AOR, 1.21; 95% CI, 1.10-1.34; P < .001, respectively). In addition, hospice regulations remained significant in fully adjusted models (AOR, 1.46; 95% CI, 1.25-1.71).

Conclusions and Relevance

The findings of this cohort study suggest that a higher percentage of assisted living residents died in place in US states with regulations supportive of third-party services. In addition, assisted living residents in licensed settings with regulations supportive of hospice regulations were especially likely to die in place.

Home-delivered meals for people with dementia: Which model delays nursing home placement? - Protocol for a feasibility pilot

BACKGROUND

Home-delivered meals promote food security, socialization, and independence among homebound older adults. However, it is unclear which of the two predominant modes of meal delivery, daily-delivered vs. drop-shipped, frozen meals, promotes community living for homebound older adults with dementia. Our objective is to present the protocol for a pilot multisite, two-arm, pragmatic feasibility trial comparing the effect of two modes of meal delivery on nursing home placement among people with dementia. We include justifications for individual randomization with different consent processes and waivers for specific elements of the trial.

METHODS

236 individuals with dementia on waiting lists at three Meals on Wheels programs' in Florida and Texas will be randomized to receive either: 1) meals delivered multiple times per week by a Meals on Wheels volunteer or paid driver who may socialize with and provide an informal wellness check or 2) frozen meals that are mailed to participants' homes every two weeks. We will evaluate and refine processes for recruitment and randomization; assess adherence to the intervention; identify common themes in participant experience; and test processes for linking participant data with Medicare records and nursing home assessment data. We will conduct exploratory analyses examining time to nursing home placement, the primary outcome for the larger trial.

CONCLUSION

This pilot will inform the follow-on large-scale, definitive pragmatic trial. In addition, the justifications for individual randomization with differing consent procedures for elements of a pragmatic trial provide a model for future trialists looking to develop ethical and feasible pragmatic studies enrolling people with dementia.

Memory care reduces nursing home admissions among assisted-living residents with dementia

INTRODUCTION

We compare nursing-home and hospital admissions among residents with Alzheimer's disease and related dementias (ADRD) in memory-care assisted living to those in general assisted living.

METHODS

Retrospective study of Medicare beneficiaries with ADRD in large (>25 bed) assisted-living communities. We compared admission to a hospital, to a nursing home, and long-term (>90 day) admission to a nursing home between the two groups, using risk differences and survival analysis.

RESULTS

Residents in memory-care assisted living had a lower adjusted risk of hospitalization (risk difference = -1.8 percentage points [P = .014], hazard ratio = 0.93 [0.87-1.00]), a lower risk of nursing-home admission (risk difference = -2.2 percentage points [P < .001], hazard ratio = 0.87 [-.79-0.95]), and a lower risk of a long-term nursing home admission (risk difference = -1.1 percentage points [P < .001], hazard ratio = 0.71 [0.57-0.88]).

DISCUSSION

Memory care is associated with reduced rates of nursing-home placement, particularly long-term stays, compared to general assisted living.

'It's not just about the dinner; it's about everything else that we do': A qualitative study exploring how Meals on Wheels meet the needs of self-isolating adults during COVID-19

Meals on Wheels (MoWs), a service offered by local authorities in England, deliver meals to older, housebound and/or vulnerable adults, who might otherwise not be able to acquire and prepare their own meals. Research suggests that MoWs provide benefits beyond nutrition. Little is known about the actual interactions between service providers and clients, particularly during the COVID-19 pandemic. The aim of this small-scale, formative study was to explore MoWs service providers' experiences and their perceptions around the benefits and challenges faced by the service, and understand how these experiences changed during the first UK national lockdown. Semi-structured interviews were conducted in September 2020 with 18 service providers of MoWs (drivers who deliver the meals, service coordinators and managers) in two local authorities in England, and analysed thematically. Participants indicated that benefits of the service encompassed those to clients (e.g. welfare checks, encouraging independence and identifying and addressing isolation and loneliness), employees (e.g. sense of pride, rewarding relationships with clients) and the wider community (e.g. reducing pressures on families), and described MoWs as the 'fourth emergency service' (e.g. being the first responders to emergency situations). Participants identified several challenges faced by the MoWs service, including organisational challenges (e.g. funding cuts and closures, lack of appropriate publicity to raise awareness of the service) and restrictions on time spent with clients. The pandemic and lockdown resulted in increased demand on resources, concerns about client and staff wellbeing and uncertainty about how the service will cope if lockdowns continue. These findings provide important insights regarding the wide benefits of MoWs and the challenges the service faces, which can be used as the formative research base to guide future interventions and policies to protect vulnerable adults, not only during the COVID-19 pandemic, but beyond.

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel: A Consensus Statement

IMPORTANCE

Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents' medical and mental health needs. No guidance exists to inform this care.

OBJECTIVE

To identify consensus recommendations for medical and mental health care in AL and determine whether they are pragmatic.

EVIDENCE REVIEW

A Delphi consensus statement study was conducted in 2021; as a separate effort, the extent to which the recommendations are reflected in practice was examined in data obtained from 2016 to 2021 (prepandemic). In the separate effort, data were from a 7-state study (Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania, Texas). The 19 Delphi panelists constituted nationally recognized experts in medical, nursing, and mental health needs of and care for older adults; dementia care; and AL and long-term care management, advocacy, regulation, and education. One invitee was unavailable and nominated an alternate. The primary outcome was identification of recommended practices based on consensus ratings of importance. Panelists rated 183 items regarding importance to care quality and feasibility.

FINDINGS

Consensus identified 43 recommendations in the areas of staff and staff training, nursing and related services, resident assessment and care planning, policies and practices, and medical and mental health clinicians and care. To determine the pragmatism of the recommendations, their prevalence was examined in the 7-state study and found that most were in practice. The items reflected the tenets of AL, the role of AL in providing dementia care, the need for pragmatism due to the diversity of AL, and workforce needs.

CONCLUSIONS AND RELEVANCE

In this consensus statement, 43 recommendations important to medical and mental health care in AL were delineated that are highly pragmatic as a guide for practice and policy.

Dementia and COVID-19 Infection Control in Assisted Living in Seven States

Background

Assisted living (AL) is the largest residential long‐term care provider in the United States, including for persons with Alzheimer's disease and related dementias. Despite recognizing the challenge of infection control for persons with dementia, this study of 119 AL communities is the first to describe dementia‐relevant COVID‐19 infection control across different types of AL communities, and to discuss implications for the future.

Methods

From a parent study sampling frame of 244 AL communities across seven states, 119 administrators provided data about COVID‐19 infection control practices and resident behaviors. Data were collected from July 2020 through September 2021. Communities were differentiated based on the presence of beds/units dedicated for persons living with dementia, as being either dementia‐specific, mixed, or integrated. Data obtained from administrators related to feasibility of implementing seven infection control practices, and the extent to which residents themselves practiced infection prevention. Analyses compared practices across the three community types.

Results

Less than half of administrators found it feasible to close indoor common areas, all community types reported a challenge organizing group activities for safe distancing, and more than half of residents with dementia did not wear a face covering or maintain physical distance from other residents when indicated. Dementia‐specific AL communities were generally the most challenged with infection control during COVID‐19.

Conclusion

All AL community types experienced infection control challenges, more so in dementia‐specific communities (which generally provide care to persons with more advanced dementia and have fewer private beds). Results indicate a need to bolster infection prevention capacity when caring for this especially vulnerable population, and have implications for care in nursing homes as well.

Findings from Talking Tech: A Technology Training Pilot Intervention to Reduce Loneliness and Social Isolation among Homebound Older Adults

Background and Objectives

Social isolation and loneliness are common among older adults and associated with negative health outcomes including cognitive decline, depression, suicide ideation, and mortality. Information and communication technology interventions are often used to combat loneliness and social isolation; however, homebound older adults face barriers to access. This study reports findings from a novel pilot intervention, called Talking Tech, designed to reduce loneliness and social isolation in homebound older adults by providing one-on-one, in-home technology training, a tablet, and the internet, to promote digital literacy and participation in a virtual senior center.

Research Design and Methods

Twenty-one homebound older adults participated in this 14-week, volunteer-delivered program. We used qualitative interviews with participants, volunteers, and program staff, weekly progress reports from volunteers, and quantitative pre- and postintervention surveys with participants to examine experiences and to evaluate the impact of the intervention on loneliness and social isolation. Qualitative data were analyzed using content analysis and pre- and postintervention survey data were compared.

Results

Participants reported increased technological literacy and use, increased access to online activities, and improved facilitation of social connections to existing and new networks. Additionally, during interviews, many participants reported that participating in Talking Tech alleviated their loneliness. While not statistically significant, our quantitative analysis revealed trends toward decreased participant feelings of loneliness and increased technology use. Additionally, intervention adoption and retention were high, with only one participant withdrawing from the intervention.

Discussion and Implications

This evaluation of the novel Talking Tech pilot intervention provides critical insights into strategies to reduce loneliness and isolation for older adults, with implications for future research, policy, and practice. Findings demonstrate that individualized technology training may be an acceptable way to improve well-being for homebound older adults.

How Medicare Advantage plans use data for supplemental benefits decision-making

OBJECTIVES

Health care payers are increasingly experimenting with interventions to address social risk factors. With enactment of the 2018 Bipartisan Budget Act, Medicare Advantage (MA) plans have new opportunities to offer supplemental benefits that are not "primarily health-related." This article presents findings from interviews conducted with executives from MA plans regarding plan decision-making processes related to new social risk factor benefits.

STUDY DESIGN

Semistructured qualitative interviews with MA plan leadership.

METHODS

A total of 63 plan representatives from 29 unique MA plans were interviewed about the rationale for social risk-related interventions and how data are used to inform benefits expansion decisions. This paper combines qualitative interview data from 2 separate studies with similar target groups and interview guides. Interview transcripts were qualitatively analyzed to examine underlying themes.

RESULTS

Three main themes emerged: (1) Plans use multiple data sources to determine how to target benefits; (2) evidence gaps hinder decision-making to expand or offer new supplemental benefits; and (3) in the absence of sufficient evidence, some plans have their own research and quality improvement processes to maximize effectiveness.

CONCLUSIONS

Findings provide insights about opportunities and challenges that MA plans face in making decisions related to supplemental benefits designed to address members' social risk factors. Barriers include collecting, generating, and analyzing data critical to informing investments. Results highlight the need to ensure interoperability of new and existing data sources, foster shared learning opportunities, and narrow evidence gaps about specific social care interventions to inform the design and implementation of effective supplemental benefits.

Research Letter: Characterization of Older Adults Hospitalized With Traumatic Brain Injury Admitted to Long-Term Acute Care Hospitals

OBJECTIVE

To describe patient, hospital, and geographic characteristics of older adult Medicare beneficiaries hospitalized with traumatic brain injury (TBI) and admitted to long-term acute care hospitals (LTACHs).

SETTING

Acute hospital and LTACH facilities.

PARTICIPANTS

In total, 15 148 Medicare beneficiaries 65 years and older with an acute TBI hospitalization who were discharged to an LTACH.

DESIGN

This retrospective cohort study used data from Centers for Medicare & Medicaid Services' Medicare Enrollment and Provider Analysis and Review data files from 2011 to 2016.

MAIN MEASURES

Patient variables (age, sex, premorbid health burden, medical complications and procedures), hospital variables (for-profit status, bed size), and state/regional geographic variation associated with LTACH TBI admission.

RESULTS

Older adult Medicare beneficiaries admitted to LTACH facilities following TBI hospitalization were on average 77.1 years old and predominantly White males. In total, 94.6% of the sample had 2+ multimorbidities present during acute hospitalization. Average acute hospital length of stay of the sample was 19.4 days, and rates of acute mechanical ventilation of any duration and tracheostomy procedures were 56.6% and 40%, respectively. Only 4.1% of patients seen in LTACHs were discharged home after LTACH stay; the primary discharge disposition was skilled nursing facilities (41.3%). Geographic analyses indicated that selected Southern and Midwestern states had the greatest number of LTACH facilities and proportion of LTACH admissions.

CONCLUSIONS

There has been limited characterization of the hospitalized TBI population admitted to LTACHs. Our findings among older adult Medicare beneficiaries suggest this population is highly medically complex and are seldom discharged home after their LTACH stay. There are also notable geographic variations in LTACH TBI admissions across the United States. More research is warranted to understand long-term functional outcomes among this population.

Dementia diagnosis in the hospital and outcomes among patients with advanced dementia documented in the Minimum Data Set

BACKGROUND

Individuals with dementia do not always have a diagnosis of dementia noted on their hospital claims. Whether this lack of documentation is associated with patient outcomes is unknown. We examined the association between a dementia diagnosis listed on a hospital claim and patient outcomes among individuals with a Minimum Data Set (MDS) assessment.

METHODS

A retrospective cohort study was conducted using administrative claims data and nursing home MDS assessments. Hospitalized patients aged 66 and older with advanced dementia noted on an MDS assessment completed within 120 days prior to their first hospitalization in 2017 were included. Advanced dementia was defined based on an MDS diagnosis of dementia, dependency in four or more activities of daily living, and a Cognitive Function Scale score indicative of moderate to severe impairment. Multilevel regression with a random intercept at the hospital level was used to examine the relationship between documentation of dementia in inpatient hospital Medicare claims and the following patient outcomes after adjusting for patient and hospital characteristics: invasive mechanical ventilation (IMV) use, intensive care unit or coronary care unit (ICU/CCU) use, 30-day mortality, and hospital length of stay (LOS).

RESULTS

In 2017, among 120,989 patients with advanced dementia and a nursing home stay, 90.57% had a dementia diagnosis on their hospital claims. In adjusted models, documentation of a dementia diagnosis was associated with lower use of the ICU/CCU (adjusted odds ratio [AOR]: 0.78 [95% confidence interval 0.74, 0.81]), use of IMV (AOR: 0.50 [0.47, 0.54]), and 30-day mortality (AOR: 0.81 [0.77, 0.85]). Patients with a dementia diagnosis had a shorter LOS.

CONCLUSIONS

Among patients with advanced dementia, those whose dementia diagnosis was documented on their inpatient hospital Medicare claim experienced lower use of ICU/CCU, use of IMV, lower 30-day mortality, and shorter LOS than those whose diagnosis was not documented.

Consumer selection and home health agency quality and patient experience stars

OBJECTIVE

To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection.

DATA SOURCES

We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website.

DATA COLLECTION/EXTRACTION METHODS

We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users.

STUDY DESIGN

This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs.

PRINCIPAL FINDINGS

The introduction of star ratings was associated with a 0.88-percentage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries.

CONCLUSIONS

The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection.

State Variation in Potentially Burdensome Transitions Among Assisted Living Residents at the End of Life

This cohort study uses Medicare administrative claims data to describe potentially burdensome transitions among assisted living residents at the end of life and assesses variations by US state.

Out Of Reach: Inequities In The Use Of High-Quality Home Health Agencies

Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconomic factors associated with the use of high-quality home health agencies. We found that Black and Hispanic home health patients had a 2.2-percentage-point and a 2.5-percentage-point lower adjusted probability of high-quality agency use, respectively, compared with their White counterparts within the same neighborhoods. Low-income patients had a 1.2-percentage-point lower adjusted probability of high-quality agency use compared with their higher-income counterparts, whereas home health patients residing in neighborhoods with higher proportions of marginalized residents had a lower adjusted probability of high-quality agency use. Some 40-77 percent of the disparities in high-quality agency use were attributable to neighborhood-level factors. Ameliorating these inequities will require policies that dismantle structural and institutional barriers related to residential segregation.

Measuring implementation fidelity in a cluster-randomized pragmatic trial: development and use of a quantitative multi-component approach

BACKGROUND

In pragmatic trials, on-site partners, rather than researchers, lead intervention delivery, which may result in implementation variation. There is a need to quantitatively measure this variation. Applying the Framework for Implementation Fidelity (FIF), we develop an approach for measuring variability in site-level implementation fidelity. This approach is then applied to measure site-level fidelity in a cluster-randomized pragmatic trial of Music & MemorySM (M&M), a personalized music intervention targeting agitated behaviors in residents living with dementia, in US nursing homes (NHs).

METHODS

Intervention NHs (N = 27) implemented M&M using a standardized manual, utilizing provided staff trainings and iPods for participating residents. Quantitative implementation data, including iPod metadata (i.e., song title, duration, number of plays), were collected during baseline, 4-month, and 8-month site visits. Three researchers developed four FIF adherence dimension scores. For Details of Content, we independently reviewed the implementation manual and reached consensus on six core M&M components. Coverage was the total number of residents exposed to the music at each NH. Frequency was the percent of participating residents in each NH exposed to M&M at least weekly. Duration was the median minutes of music received per resident day exposed. Data elements were scaled and summed to generate dimension-level NH scores, which were then summed to create a Composite adherence score. NHs were grouped by tercile (low-, medium-, high-fidelity).

RESULTS

The 27 NHs differed in size, resident composition, and publicly reported quality rating. The Composite score demonstrated significant variation across NHs, ranging from 4.0 to 12.0 [8.0, standard deviation (SD) 2.1]. Scaled dimension scores were significantly correlated with the Composite score. However, dimension scores were not highly correlated with each other; for example, the correlation of the Details of Content score with Coverage was τb = 0.11 (p = 0.59) and with Duration was τb = - 0.05 (p = 0.78). The Composite score correlated with CMS quality star rating and presence of an Alzheimer's unit, suggesting face validity.

CONCLUSIONS

Guided by the FIF, we developed and used an approach to quantitatively measure overall site-level fidelity in a multi-site pragmatic trial. Future pragmatic trials, particularly in the long-term care environment, may benefit from this approach.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03821844. Registered on 30 January 2019, https://clinicaltrials.gov/ct2/show/NCT03821844 .

Pragmatic Trial of Personalized Music for Agitation and Antipsychotic Use in Nursing Home Residents With Dementia

OBJECTIVE

To test the effect of a personalized music intervention on agitated behaviors and medication use among long-stay nursing home residents with dementia.

DESIGN

Pragmatic, cluster-randomized controlled trial of a personalized music intervention. Staff in intervention facilities identified residents' early music preferences and offered music at early signs of agitation or when disruptive behaviors typically occur. Usual care in control facilities may include ambient or group music.

SETTING AND PARTICIPANTS

The study was conducted between June 2019 and February 2020 at 54 nursing homes (27 intervention and 27 control) in 10 states owned by 4 corporations.

METHODS

Four-month outcomes were measured for each resident. The primary outcome was frequency of agitated behaviors using the Cohen-Mansfield Agitation Inventory. Secondary outcomes included frequency of agitated behaviors reported in the Minimum Data Set and the proportion of residents using antipsychotic, antidepressant, or antianxiety medications.

RESULTS

The study included 976 residents with dementia [483 treatment and 493 control; mean age = 80.3 years (SD 12.3), 69% female, 25% African American]. CMAI scores were not significantly different (treatment: 50.67, SE 1.94; control: 49.34, SE 1.68) [average marginal effect (AME) 1.33, SE 1.38, 95% CI -1.37 to 4.03]. Minimum Data Set-based behavior scores were also not significantly different (treatment: 0.35, SE 0.13; control: 0.46, SE 0.11) (AME -0.11, SE 0.10, 95% CI -0.30 to 0.08). Fewer residents in intervention facilities used antipsychotics in the past week compared with controls (treatment: 26.2, SE 1.4; control: 29.6, SE 1.3) (AME -3.61, SE 1.85, 95% CI -7.22 to 0.00), but neither this nor other measures of psychotropic drug use were statistically significant.

CONCLUSIONS AND IMPLICATIONS

Personalized music was not significantly effective in reducing agitated behaviors or psychotropic drug use among long-stay residents with dementia. Barriers to full implementation included engaging frontline nursing staff and identifying resident's preferred music.

Fewer potentially avoidable health care events in rural veterans with self-directed care versus other personal care services

BACKGROUND

Rural residents face more barriers to healthcare access, including challenges in receiving home- and community-based long-term services, compared to urban residents. Self-directed services provide flexibility and choice in care options and may be particularly well suited to help older adults with multiple chronic conditions and functional limitations who reside in rural areas remain independent and live in the community.

METHODS

We conducted a retrospective observational study to understand whether differences in health outcomes between Veteran-Directed Care (VDC), a self-directed Veterans Health Administration (VHA)-paid care program, and other VHA-paid home- and community-based personal care services vary in rural/urban location. The sample included 37,395 veterans receiving VHA-paid home- and community-based long-term care services in FY17. Our primary outcomes were changes in monthly incidence of VHA or VHA-paid community acute care admissions, nursing home admissions, and emergency department (ED) visits. We used fixed effects logistic regression models on unmatched and coarsened exact matched cohorts, stratified by rural/urban location.

RESULTS

Both urban and rural VDC recipients were significantly less likely to be admitted to VHA-paid nursing homes, compared to those receiving other VHA-paid personal care services (rural: incremental effect = -0.22, [-0.30, -0.14]; urban: incremental effect = -0.14, [-0.20, -0.07]). Rural, but not urban, VDC enrollees had significantly fewer VHA-paid acute care admissions and ED visits, relative to recipients of other VHA-paid personal care services (acute care, rural: incremental effect = -0.07, 95% CI = [-0.14, -0.01], urban: incremental effect = -0.01, [-0.06, 0.03]; ED, rural: incremental effect = -0.08, [-0.14, -0.02], urban: incremental effect = 0.01, [-0.03, 0.05]).

CONCLUSIONS

VDC recipients had fewer incidents of potentially avoidable VHA-paid health care use, compared to similar veterans receiving other VHA-paid personal care services. These differences were more pronounced among rural VDC recipients than urban VDC recipients.

The Imperative to Reimagine Assisted Living

Assisted living (AL) has existed in the United States for decades, evolving in response to older adults' need for supportive care and distaste for nursing homes and older models of congregate care. AL is state-regulated, provides at least 2 meals a day, around-the-clock supervision, and help with personal care, but is not licensed as a nursing home. The key constructs of AL as originally conceived were to provide person-centered care and promote quality of life through supportive and responsive services to meet scheduled and unscheduled needs for assistance, an operating philosophy emphasizing resident choice, and a residential environment with homelike features. As AL has expanded to constitute half of all long-term care beds, the increasing involvement of the real estate, hospitality, and health care sectors has raised concerns about the variability of AL, the quality of AL, and standards for AL. Although the intent to promote person-centered care and quality of life has remained, those key constructs have become mired under tensions related to models of AL, regulation, financing, resident acuity, and the workforce. These tensions have resulted in a model of care that is not as intended, and which must be reimagined if it is to be an affordable care option truly providing quality, person-centered care in a suitable environment. Toward that end, 25 stakeholders representing diverse perspectives conferred during 2 half-day retreats to identify the key tensions in AL and discuss potential solutions. This article presents the background regarding those tensions, as well as potential solutions that have been borne out, paving the path to a better future of assisted living.

State Regulations and Hospice Utilization in Assisted Living during the Last Month of Life

OBJECTIVES

To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization.

DESIGN

Retrospective cohort study of fee-for-service Medicare beneficiaries who died in 2018 and resided in an RC/AL community with ≥25 beds at least 1 day during the last month of life.

SETTING/PARTICIPANTS

23,285 decedents who spent time in 6274 RC/AL communities with 146 state license classifications.

METHODS

Descriptive statistics about hospice use; logistic regression models to test the association between regulations supportive of hospice care or registered nurse (RN) staffing requirements and the odds of hospice use in RC/AL in the last month of life.

RESULTS

More than half (56.4%) of the study cohort received hospice care in RC/AL at some point during the last 30 days of life, including 5.7% who received more intensive continuous home care (CHC). A larger proportion of decedents who resided in RC/ALs with supportive hospice policies received hospice (57.3% vs 52.6%), with this difference driven by more CHC hospice programs. This association remained significant after controlling for sociodemographic characteristics, comorbidities, time spent in RC/AL, and Hospital Referral Region fixed effects. Decedents in RC/ALs with explicit RN staffing requirements had significantly less CHC use (2.0% vs 6.8%).

CONCLUSIONS AND IMPLICATIONS

A large proportion of RC/AL decedents received hospice care in RC/AL regardless of differing regulations. Those in licensed settings with explicitly supportive hospice regulations were significantly more likely to receive hospice care in RC/AL during the last month of life, especially CHC level of hospice care. Regulatory change in states that do not yet explicitly allow hospice care in RC/AL may potentially increase hospice utilization in this setting, although the implications for quality of care remain unclear.

A Technology Training Program to Alleviate Social Isolation and Loneliness Among Homebound Older Adults: A Community Case Study

Despite substantial evidence of the negative health consequences of social isolation and loneliness and the outsized impact on older adults, evidence on which interventions are most effective in alleviating social isolation and loneliness is inconclusive. Further complicating the translation of evidence into practice is the lack of studies assessing implementation and scalability considerations for socialization programs delivered by community-based organizations (CBOs). Our primary objective was to describe the implementation barriers, facilitators, and lessons learned from an information and communication technology (ICT) training program aimed at reducing social isolation and loneliness for homebound older adults in a home-delivered meals program. Participants received in-home, one-on-one ICT training lessons delivered by volunteers over a 14-week period with the goal of increasing social technology use. To assess implementation facilitators and barriers, 23 interviews were conducted with program staff (n = 2), volunteers (n = 3), and participants (n = 18). Transcripts were analyzed using thematic analysis. Aspects that facilitated implementation included the organization's existing relationship with clientele, an established infrastructure to deliver community-based interventions, alignment of intervention goals with broader organizational aims, and funding to support dedicated program staff. Challenges to implementation included significant program staff time and resources, coordinating data sharing efforts across multiple project partners, participant and volunteer recruitment, and interruptions due to COVID-19. Implications of these facilitators and barriers for scalability of community-based ICT training interventions for older adults are described. Lessons learned include identifying successful participant and volunteer recruitment strategies based on organizational capacity and existing recruitment avenues; using a targeted approach to identify potential participants; incorporating flexibility into intervention design when working with the homebound older adult population; and monitoring the participant-volunteer relationship through volunteer-completed reports to mitigate issues. Findings from this formative evaluation provide insight on strategies CBOs can employ to overcome challenges associated with implementing technology training programs to reduce social isolation and loneliness for older adults, and thus improve overall well-being for homebound older adults. Recommendations can be integrated into program design to facilitate implementation of ICT programs in the community setting.