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Medicaid-funded home and community-based services (HCBSs) reach large numbers of individuals living with dementia who would otherwise reside in nursing homes with Medicaid funding. Medicaid HCBSs also often augment care provided by family and other informal caregivers to individuals living with dementia. Although Medicaid-funded HCBSs are offered in most states in lieu of nursing home care, they have been largely overlooked as health care system partners for implementation and testing of evidence-based dementia care interventions using embedded pragmatic clinical trial (ePCT) designs. In this article, we make the case for the importance of Medicaid-funded HCBSs as dementia care ePCT partners because of the volume of vulnerable clients with dementia served and the potential positive impacts that evidence-based dementia care programs can have on clients and their informal caregivers. This article first characterizes the Medicaid HCBS setting in terms of populations served and organizational arrangements across states. We then characterize strengths and potential limitations presented by Medicaid HCBSs as settings within which to implement dementia care ePCTs, using as a conceptual framework the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool and its domains. We draw on our experiences implementing the Care of Persons with Dementia in their Environments (COPE) program in a statewide Medicaid HCBS setting to highlight how these potential ePCT partners can help optimize pragmatic approaches to several PRECIS-2 domains. We found that partners are especially effective in implementing pragmatic ways to determine eligibility for evidence-based dementia care programs; assist with recruitment of eligible individuals; incorporate dementia care interventions into the range of existing HCBSs; and track outcomes relevant to persons living with dementia, caregivers, HCBS providers, and Medicaid insurance stakeholders. We conclude with recommendations for researchers, potential ePCT partners, and policymakers to help facilitate the growth of dementia care ePCTs in Medicaid HCBS settings across the United States. [ABSTRACT FROM AUTHOR]

Abstract The first National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers was held on October 16-17, 2017, at the National Institutes of Health. In this paper, participants from the Summit Session on Research on Care Needs and Supportive Approaches for Persons with Dementia summarize the state of the science, identify gaps in knowledge, and offer recommendations to improve science and practice in long-term care. Recommendations cover 4 areas focused on persons living with dementia: (1) symptoms (behavioral and psychological symptoms of dementia, function, cognition, and sleep); (2) dementia care settings (physical and social environments, home, and residential care); (3) living with dementia (living well with dementia, living alone with dementia, and living with dementia and intellectual and developmental disabilities); and (4) technology as a cross-cutting theme. The participants identify 10 of the most pressing research issues based on the findings from their collective papers. Final Summit recommendations included those presented by session participants and will be used to advise federal agencies and other organizations that fund research. [ABSTRACT FROM AUTHOR]

Objectives: This study examined a multicommunity alternative transportation program available 24 hours a day, 7 days a week, for any purpose, offering door-through-door service in private automobiles to members who either do not drive or are transitioning away from driving. Specific aims were to describe the characteristics of members by driving status and ride service usage of these members.Methods: Data came from administrative records maintained by a nonprofit ride service program and include 2,661 individuals aged 65+ residing in 14 states who joined the program between April 1, 2010, and November 8, 2013. Latent class analysis was used to group current drivers into 3 classes of driving status of low, medium, and high self-regulation, based on their self-reported avoidance of certain driving situations and weekly driving frequency. Demographics and ride service use rate for rides taken through March 31, 2014, by type of ride (e.g., medical, social, etc.) were calculated for nondrivers and drivers in each driving status class.Results: The majority of ride service users were female (77%) and aged 65-74 years (82%). The primary method of getting around when enrolling for the transportation service was by riding with a friend or family member (60%). Among the 67,883 rides given, nondrivers took the majority (69%) of rides. Medical rides were the most common, accounting for 40% of all rides.Conclusions: Reported ride usage suggests that older adults are willing to use such ride services for a variety of trips when these services are not limited to specific types (e.g., medical). Further research can help tailor strategies to encourage both nondrivers and drivers to make better use of alternative transportation that meets the special needs of older people. [ABSTRACT FROM AUTHOR]

Older adults with dementia care needs often visit primary care physicians (PCPs), but PCP dementia care limitations are widely documented. This study tested the value of employing a nurse practitioner (NP) with geropsychiatric expertise to augment PCP care for newly and recently diagnosed patients and family caregivers. Twenty-one dyads received the NP intervention; 10 dyads were controls. Outcomes included patient neuropsychiatric symptom and quality of life changes, and caregiver depression, burden, and self-efficacy changes. Intervention acceptability by patients, caregivers, and PCPs was determined. No outcome differences were found; however, the NP intervention was deemed highly satisfactory by all stakeholders. Patients experienced no significant cognitive decline during the 12-month study period, helping explain why outcomes did not change. Given widespread acceptability, future tests of this PCP-enhancing intervention should include patients with more progressive cognitive decline at study entry. NPs with geropsychiatric expertise are ideal interventionists for this rapidly growing target population. [ABSTRACT FROM AUTHOR]

The journey for people with Alzheimer's disease or another dementia involves the need for increasing levels of support, with transitions across care settings. Although transitional care has received increasing attention in the health care arena, no widely accepted transitions typology exists for the dementia journey. At the same time, national dementia strategies are proliferating. We developed a typology containing six transitions that cover the dementia journey from symptom recognition to end-of-life care. We then critically evaluated whether and how the national dementia strategies of Australia, England, France, the Netherlands, Norway, Scotland, and the United States addressed each transition. Adopting a person-centered perspective, we found that most or all of the national strategies adequately address earlier transitions in the journey, but fewer strategies address the later transitions. We recommend that next-generation national dementia strategies focus on later transitions, specify how care coordination and workforce training should make transitions more person centered, and use person-centered outcomes in evaluating the success of the strategies' implementation and dissemination. [ABSTRACT FROM AUTHOR]

Objective: The primary objective is to report on the efficacy of an individualized dementia care consultation intervention for family caregivers of patients with diagnosed dementia living in the community. The secondary objective is to present evidence on the intervention process to inform the feasibility and sustainability of the model featuring collaboration between primary care physicians and a voluntary sector organization. Method: Randomization was based on primary care physician practice site. In the intervention group, dementia care consultants located at an Alzheimer's association chapter provided individualized counseling and support over a 12-month period, and sent copies of care plans developed with family caregivers to referring primary care physicians. In the control group, family caregivers received educational and community resource information but no care consultation. Nursing home admission of patients during the 12-month study period was the primary outcome; secondary outcomes included measures of caregiver self-efficacy for managing dementia, caregiver depressive symptoms, and caregiver burden. Results: A total of 84 family caregivers participated. After adjusting for baseline characteristics, patients whose family caregivers were in the intervention group were less likely than their control group counterparts to be admitted to a nursing home (Adjusted odds ratio = 0.40; 95% C.I. = 0.14-1.18; p = 0.10). No other outcomes were significantly different between treatment groups; however, intervention group caregivers reporting greater satisfaction with the intervention showed improved self-efficacy for managing dementia compared to their less satisfied counterparts. Medical record reviews found that care plans were found in most patient records, but that only 27% of intervention group caregivers reported discussing these care plans with physicians. Three different individuals occupied the dementia care consultant position during the study period, and this turnover led to family caregiver dissatisfaction. Conclusion: The dementia care consultation intervention showed favorable effects on nursing home admission and on caregiver outcomes among intervention group caregivers more satisfied with the intervention, but there are important barriers to sustaining this collaboration between primary care physicians and a voluntary sector organization such as an Alzheimer's association chapter. [ABSTRACT FROM AUTHOR]

The financial ability to pay for food and medical care is needed to maintain health in older persons following a serious illness. Therefore, we hypothesize that the inability to pay for basic needs, which we call financial disability, predicts adverse health outcomes in older patients discharged from the hospital.To determine the frequency of reported financial disability in older adults being discharged from a hospital, to determine patient characteristics associated with financial disability, and to examine the relationship between financial disability and functional decline and mortality.Prospective cohort study.Two thousand two hundred patients 70 years and older admitted to the general medicine services at two teaching hospitals in Ohio.Respondents were interviewed at the time of discharge to determine patients' financial ability to pay for 6 needs: groceries, general bills, medications, medical bills, a small emergency, and a major emergency. We determined functional decline in ability to perform activities of daily living from discharge to 90 days post–hospital discharge, and death 1 year after hospital discharge.Financial disability was reported to be severe (unable to pay for 3–6 needs) for 21% of patients and moderate (unable to pay for 1–2 needs) for 36%. Financial disability was more common and more severe (P<.001) in persons with an annual household income less than$10,000, in persons with fewer than 12 years of formal education, in African Americans, and in women. In patients with no financial disability, moderate financial disability, and severe financial disability, functional decline 3 months after hospital discharge occurred in 15%, 20%, and 25%, respectively (P=.001), and 1-year mortality rates were 24%, 27%, and 32%, respectively (P=.002). After adjustment for potential confounders, the association of financial disability with functional decline (P=.003) and mortality (P=.02) remained significant.Reports of financial disability at hospital discharge identified vulnerable older adults with increased risk for functional decline and death. Interventions that alleviate financial disability may improve health outcomes in older adults discharged from hospital. [ABSTRACT FROM AUTHOR]

Expected changes in home health care reimbursement will require a shift in focus from a visit-based unit to some other yet-to-be-defined unit of resource consumption. Little research has been done to understand other measures of resource consumption, however, especially those examining disciplinary differences. The purpose of this study was to provide empirical evidence on other measures of resource consumption as a way to frame discussions on alternative measures. Information is presented from a study of 102 home health care patients from 10 agencies in Ohio who completed an episode of care and remained at home. While the mean time per visit was similar for all disciplines (46 to 55 minutes), there were differences in the number of visits provided by various disciplines (home care aide services had the highest mean number of visits with 11.8). The mean cost per day for all services was $43.80 while the mean cost per episode was $1,160. Recommendations for further research include similar examinations using a more rigorous sampling methodology and including disparate populations of patients. [ABSTRACT FROM AUTHOR]

Studies how office-based primary care physicians in Maine, New Hampshire and Vermont diagnose and manage older persons and families with dementia symptoms. Differences in diagnostic approaches; Diagnostic and symptom management issues discussed by the physicians with the patients; Referrals made by the physicians about health and social services.

Presents the results of a study which examined the relationships between measures of home care resource consumption, and patient outcome measures, in patients who began home care with Medicare-certified home agencies in Ohio. How home care resource consumption is associated with patient trajectories into and out of episodes of home care.

Objective: To examine the relation between two patient outcome measures that can be used to assess the quality of hospital care: changes in health status between admission and discharge, and patient satisfaction.Design: Prospective cohort study.Setting and Patients: Subjects were 445 older medical patients (aged > or =70 years) hospitalized on the medical service of a teaching hospital.Measurements and Main Results: We interviewed patients at admission and discharge to obtain two measures of health status: global health and independence in five activities of daily living (ADLs). At discharge, we also administered a 5-item patient satisfaction questionnaire. We assessed the relation between changes in health status and patient satisfaction in two sets of analyses, that controlled for either admission or discharge health status. When controlling for admission health status, changes in health status between admission and discharge were positively associated with patient satisfaction (p values ranging from .01 to .08). However, when controlling for discharge health status, changes in health status were no longer associated with patient satisfaction. For example, among patients independent in ADLs at discharge, mean satisfaction scores were similar regardless of whether patients were dependent at admission (i.e., had improved) or independent at admission (i.e., remained stable) (79.6 vs 81.2, p = .46). Among patients dependent in ADLs at discharge, mean satisfaction scores were similar regardless of whether they were dependent at admission (i.e., remained stable) or independent at admission (i.e., had worsened) (74.0 vs 75.7, p = .63). These findings were similar using the measure of global health and in multivariate analyses.Conclusions: Patients with similar discharge health status have similar satisfaction regardless of whether that discharge health status represents stable health, improvement, or a decline in health status. The previously described positive association between patient satisfaction and health status more likely represents a tendency of healthier patients to report greater satisfaction with health care, rather than a tendency of patients who improve following an interaction with the health system to report greater satisfaction. This suggests that changes in health status and patient satisfaction are measuring different domains of hospital outcomes and quality. Comprehensive efforts to measure the outcomes and quality of hospital care will need to consider both patient satisfaction and changes in health status during hospitalization. [ABSTRACT FROM AUTHOR]

Examines the prevalence of pressure ulcer in several nursing homes in Ohio. Risk factors of pressure ulcer; Purpose of the study; Approach used in data gathering.

Investigates the relationship between race and strain in family caregivers of hospitalized older patients from a sample of 176 African Americans and 194 White American caregivers. Relationship between race and strain; Need for hospital staff to be sensitive to racial diversity when working with families to plan for older patients' discharge.

Some studies suggest that ambient particulate air pollution is associated with cognitive decline. However, the findings are mixed, and there is no relevant research examining the influences of ultrafine particles (UFP), which may have more toxicity than larger particles. We therefore conducted this study to investigate whether residential UFP exposure is associated with cognitive decline using data from the Alzheimer's Disease Research Centers in the United States. This is a longitudinal study of participants who were aged 65 years and older and had normal cognitive status at baseline. Residential UFP exposure, expressed as particle number concentrations (PNC), was assessed in 2016–2017 using a nationwide land use regression model, and was assigned to each participant using their 3-digit residential ZIP codes. Cognitive functions including memory, attention, language, executive function, and global function were assessed annually using 15 neuropsychological tests from March 2015 to February 2022. Linear mixed-effects models were used to examine the associations after adjustment for covariates including baseline age, sex, APOE ε4 status, race, education, smoking status, history of diabetes, quartiles of neighborhood median household income, and interaction terms of follow-up time with each covariate. This study included 5646 participants (mean age 76 years, 65% female). On average, each participant had 4 annual visits. When PNC was treated as a continuous variable, there were no statistically or clinically significant changes in annual decline of each cognitive function in relation to an interquartile range elevation in PNC (4026 particles/cm3). Similarly, when PNC was treated as a categorical variable including five exposure groups, there were no linear exposure-response trends in annual decline of each cognitive function across the five exposure groups. This study found no meaningful associations between residential UFP exposure and cognitive decline in global and domain-specific functions. There is a need for further research that assigns UFP exposure at a finer geographic scale. • APOE ε4 carriers had faster annual decline in every cognitive function. • Smoking was associated with faster decline in memory and executive function. • Higher income neighborhoods had greater exposure to ultrafine particles. • No meaningful association was found between ultrafine particles and cognitive decline. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Functional capacity is widely recognized as a key factor in maintaining the ability of older people to live independently and safely at home. Promoting functional capacity is an important priority particularly in HHC. The purpose of the study was to examine predictors of functional capacity change among HHC patients with HF. Materials and methods: Clinical and administrative data from 2005 from the Medicare Chronic Conditions Warehouse were linked at the population level for HHC patients with a primary diagnosis of HF. The primary outcome was change in functional capacity score from HHC admission to HHC discharge. Results: Over the course of the episode (M =44 days), most (70%) patients improved, 15.6% stayed the same, and 14.4% declined in activities of daily living (ADL) scores. The mean change score was modest (mean=−0.74, SD=1.11) with a median change of −0.58. Multivariate analyses (R 2 =0.23) showed that the largest influence was the admission ADL score followed by receiving any physical therapy (PT), admission ability to manage oral medications, cognitive functioning, rehabilitation prognosis, and urinary incontinence. Discussion: There is a modest rate of improvement from admission to discharge that likely represents the progressive nature of HF and/or the short time frames over which HHC is provided. Providers may want to use the predictive factors to identify patients most at risk for functional decline. [Copyright &y& Elsevier]

Up to 75% of hip fracture patients never recover to their pre-fracture functional status. Supervised exercise that includes strength training can improve functional recovery after hip fracture. The role of testosterone replacement for augmenting the effects of exercise in older women after hip fracture is unknown. The Starting Testosterone and Exercise after Hip Injury (STEP-HI) Study is a 6-month Phase 3 multicenter randomized placebo-controlled trial designed to compare supervised exercise (EX) plus 1% testosterone topical gel, with EX plus placebo gel, and with enhanced usual care (EUC). Female hip fracture patients age ≥ 65 years are being recruited from clinical centers across the United States. Participants are community dwelling and enrolled within 24 weeks after surgical repair of the fracture. The EX intervention is a center-based program of progressive resistance training. The EUC group receives a home exercise program and health education. Participants receive dietary counseling, calcium and vitamin D. The primary outcome is the Six Minute Walk Distance. Secondary outcomes include physical performance measures, self-reported function and quality of life, and dual energy x-ray absorptiometry measures of body composition and bone mineral density. Enrollment, interventions, and follow-up are ongoing. We describe the impact of the coronavirus disease 2019 pandemic on the trial, including modifications made to allow continuation of the interventions and outcome data collection using remote video and audio technology. Results from the STEP-HI study are expected to have important clinical and public health implications for management of the growing population of hip fracture patients. • Hip fractures in older women are a major public health problem of increasing magnitude. • Most patients do not reach their pre-fracture mobility status after successful surgical repair of a hip fracture. • Exercise can improve physical function after hip fracture surgery. • Testosterone replacement can augment the effects of exercise but its efficacy is unknown in older women with hip fracture. • Topical testosterone plus high-intensity exercise may improve strength and physical function in women after hip fracture. • RRe Results of the STEP-HI study may help to guide decisions on therapies to improve outcomes after hip fracture in older women. [ABSTRACT FROM AUTHOR]

Objective: While racial, ethnic, and socioeconomic group disparities in cognitive impairment and dementia prevalence are well-documented among community-dwelling older adults, little is known about these disparity trends among older adults receiving Medicaid-funded home- and community-based services (HCBS) in lieu of nursing home admission. The authors determined how dementia prevalence and cognitive impairment severity compare by race, ethnicity, educational attainment, and neighborhood context in a Medicaid HCBS population., Design/setting: A cross-sectional study in Connecticut., Participants: Adults age ≥65 in the HCBS program, January-March 2019 (N = 3,520)., Measurements: The data source was Connecticut's HCBS program Universal Assessment tool. The authors employed two outcomes: Cognitive Performance Scale (CPS2), a 9-point measure ranging from cognitively intact-very severe impairment; and presence or not of either diagnosed dementia or CPS2 score ≥4 (major impairment). Neighborhood context was measured using the Social Vulnerability Index (SVI)., Results: Cohort characteristics: 75.7% female; mean(SD) age = 79.1(8.2); Non-Hispanic White = 47.8%; Hispanic = 33.6%; Non-Hispanic Black = 15.9%. Covariate-adjusted multivariate analyses revealed no dementia/major impairment prevalence differences among White, Black, and Hispanic individuals, but impairment severity was greater among Hispanic participants (b = 0.22; p = 0.02). People with more than HS education had less severe impairment (b = -0.12; p <0.001) and lower likelihood of dementia/major impairment (AOR = 0.61; p <0.001). Dementia/major impairment likelihood and impairment severity were greater in less socially vulnerable neighborhoods., Conclusion: Racial and ethnic group differences in cognitive impairment are less pronounced in Medicaid-funded HCBS cohorts than in other community-dwelling older adult cohorts. SVI results suggest that, among other possible explanations, older adults with dementia may move to lower social vulnerability neighborhoods where supportive family members reside., (Copyright © 2022 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Care transitions are frequent among patients with dementia. This study aimed to estimate the impact of continuity of care (COC) on successful community discharge after hospitalization., Methods: National Veterans Health Administration data linked to Medicare claims in fiscal years 2014-2015. Community-dwelling older veterans with dementia with an acute hospitalization were included ( n = 31,648). COC was measured by the Bice-Boxerman Continuity of Care (BBC) index (0-1). Association of COC before hospitalization on successful community discharge was examined separately among veterans discharged to the community directly and through post-acute care facilities., Results: Veterans with a 0.1 higher BBC were 4.6% ( p = .06) more likely to have successful direct community discharge; but BBC had no demonstrable effect when discharge was through post-acute care facilities., Conclusion: Better COC may have impact at improving successful direct community discharge, although the effect is small and the type I error rate (statistical significance) was 6%.

Objectives: To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia., Data Sources: Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015., Study Design: FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders., Data Collection: Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073)., Principal Findings: Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost., Conclusions: COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care., (© Health Research and Educational Trust.)

Background: Dementia, depression, and delirium alone or in combination (3Ds) can threaten independence among older adults, and polypharmacy may further accelerate decline. Clinical pharmacists can play an important role on multidisciplinary home-based care teams by identifying medication therapy problems (MTPs) involving cognition. Within a larger ongoing clinical trial, this paper describes cognition-related MTPs and pharmacist recommendations among older adults with 3Ds followed by a home-based care team., Methods: We conducted a retrospective analysis of medication data among Medicare Advantage members aged ≥ 65 years living at home in Connecticut with International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes related to 3Ds; analyses include the first 105 subjects randomized to the home-based care team from March 2017 to January 2019. Advanced practice registered nurses conducted in-home medication reconciliations along with medical and cognitive assessments. Clinical pharmacists then conducted medication reviews centered on agents treating or exacerbating 3Ds. After review by the study advanced practice registered nurse, geriatrician, and psychiatrist, salient recommendations were forwarded to primary care providers for consideration. Medication therapy problems related to cognition were retrospectively abstracted and classified as: (1) indication: underuse or overuse; (2) effectiveness: ineffective agent or low dose (mainly for antidepressants); and (3) safety: undesirable effect (e.g., impaired cognition, dementia treatment side effects), unsafe medication (e.g., potentially inappropriate medications that can harm cognition), drug interaction, or high dose., Results: Pharmacists identified 166 cognitive MTPs, with a mean (standard deviation) of 1.58 (1.35) [range 0-6] MTPs per subject. Indication MTPs represented 34% of total MTPs, of which 79% involved underuse and 21% overuse; effectiveness represented 13% of total MTPs; and safety represented over half (52%) of all MTPs, with benzodiazepines and anticholinergics frequently implicated. Recommendations commonly included medication reduction (discontinuation 23% and dose reduction 19%). We found MTPs involving cognition among most (79%) patients., Conclusions: Our study findings support the role of pharmacists on multidisciplinary teams to identify cognitively harmful medications, dementia treatment side effects, and untreated cognitive conditions., Clinical Trial Registration: ClinicalTrials.gov NCT02945085.

Background: Hospitalization is a difficult experience, especially for patients with dementia. Understanding whether better continuity of care (COC) reduces hospitalizations can indicate interventions that might help curb hospitalizations., Objective: To estimate the causal impact of COC on hospitalizations and different reasons for hospitalization among community-dwelling older veterans with dementia., Research Design: Population-based observational study using nationwide Veterans Health Administration data linked to Medicare claims in Fiscal Years (FYs) 2014-2015. To account for unobserved confounders we used an instrumental variable for COC-whether veteran changed residence by more than 10 miles., Subjects: Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (n=105,528)., Measures: Bice-Boxerman Continuity of Care (BBC) index (0-worst to 1-best COC); binary indicators of any hospitalization for all causes, for ambulatory care sensitive conditions (ACSCs) and for reasons grouped by major diagnostic category., Results: The mean BBC in FY 2014 was 0.32 (SD, 0.23). In FY 2015 43.3% of the cohort veterans were hospitalized. A 0.1 higher BBC resulted in 2.4% (95% confidence interval, 0.5%-4.4%) lower probability of hospitalization for all causes. BBC was not associated with hospitalization for ACSCs. Grouped by major diagnostic category, a 0.1 higher BBC resulted in 3.8% (95% confidence interval, 2.1%-5.4%) lower probability of hospitalization for neuropsychiatric diseases/disorders, with no impact on hospitalizations for circulatory, respiratory, infectious, kidney and urinary, digestive, musculoskeletal, and endocrine-metabolic diseases/disorders., Conclusions: Among community-dwelling older veterans with dementia, better COC resulted in less hospitalizations, and this effect was primarily due to less hospitalization for neuropsychiatric diseases/disorders but not hospitalization for ACSCs, or other hospitalization reasons.

Objectives: To characterize the cumulative risk factors of social and behavioral determinants of health (SDoH) and examine their association with self-rated general health, functional limitations, and use of health services among US older adults., Design: Cross-sectional analysis of the 2013-2014 National Health and Nutrition Examination Survey., Setting: Nationally representative health interview survey in the United States., Participants: Survey respondents aged 65 or older (n = 1,306 unweighted)., Measurements: A cumulative risk score of SDoH, developed by the National Academy of Medicine expert panel, was assessed using validated measures. Outcome variables included self-rated general health, functional limitations (eg, activities of daily living), and use of health services (eg, usual source of care and overnight hospitalization). We quantified the cumulative risk score of SDoH in older adults and used multivariable-adjusted logistic and Poisson regression analyses to assess the association of SDoH with self-rated health, functional limitations, and use of health services, adjusting for other covariates., Results: About 25.7% of older adults, representative of 11.0 million people nationwide, reported having three or more cumulative SDoH risk factors. These older adults were more likely to have functional limitations (eg, activities of daily living) and less likely to report their general health as "very good" or "excellent" than those with two or fewer cumulative SDoH risk factors (P < .001 for each). Each additional cumulative SDoH risk factor was associated with increased odds of not having a usual source of care (adjusted odds ratio = 1.57; 95% confidence interval = 1.09-2.27)., Conclusion: The SDoH index score may be a useful tool to predict access to care and quality of care in older adults. J Am Geriatr Soc 68:1731-1738, 2020., (© 2020 The American Geriatrics Society.)

Care management approaches are being widely tested in the Medicare-eligible population to manage chronic conditions, but few have focused on cognitive vulnerability as the pathway to optimizing independence in the community-dwelling older population. Cognitive vulnerability refers to living with dementia, depression, and/or a history of delirium. Many studies have shown that cognitive vulnerability is associated with poor health-related outcomes in community-dwelling older adults, raising the health policy importance of finding evidence-based approaches to improve outcomes for this target population. Moreover, very little is known about effects of care management approaches in the rapidly growing Medicare Advantage population. In response to these knowledge gaps, we are testing the efficacy of an in-home, nurse practitioner-led care management team for adults age ≥ 65 with cognitive vulnerability in a Medicare Advantage population. Older adults and family caregivers randomized either to this multidisciplinary care management team, or to a telephonic care management program routinely offered by our Medicare Advantage partner. The intervention period is 12 months and the primary outcome is any emergency department visit or hospitalization over the 12-month period. In this paper, we report on the rationale for testing a multidisciplinary care management intervention for this target population, and explain how a university-based research team collaborated with a Medicare Advantage insurer to conceptualize and implement the clinical trial. We also provide details on study design, and on components of the in-home and telephonic care management interventions. We conclude with a synopsis of recruitment progress along with selected baseline characteristics of the study cohort., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: This study examined how work and family demands affect depressive symptoms, and the mediating roles of work-to-family conflict and family-to-work conflict in a sample of correctional supervisors., Methods: Using a cross-sectional design, correctional supervisors working in a Northeastern state (n = 156) participated in an online survey. Structural equation modeling was used to examine direct and indirect effects between study variables., Results: Amount of overtime hours worked significantly predicted work-to-family conflict (β = 0.18, P < 0.05), and work-to-family conflict significantly predicted greater depressive symptoms (β = 0.61, P < 0.01). Overtime work also had an indirect effect on depressive symptoms through work-to-family conflict (β = 0.11 [95% CI 0.001-0.42]). No other statistically significant effects of relevance were found., Conclusions: Working overtime had an indirect effect on correctional supervisors' depressive symptoms, mediated by work-to-family conflict.

Background: Dementia is the leading cause of loss of independence in older adults worldwide. In the U.S., approximately 15 million family members provide care to relatives with dementia. This paper presents the rationale and design for a translational study in which an evidence-based, non-pharmacologic intervention for older adults with dementia and family caregivers (CGs) is incorporated into a publicly-funded home care program for older adults at risk for nursing home admission., Methods: The 4-month Care of Persons with Dementia in their Environments (COPE) intervention is designed to optimize older adults' functional independence, and to improve CG dementia management skills and health-related outcomes. COPE features 10 in-home occupational therapy visits, and 1 in-home visit and 1 telephone contact by an advanced practice nurse. COPE was deemed efficacious in a published randomized clinical trial. In the present study, older adults with dementia enrolled in the Connecticut Home Care Program for Elders (CHCPE) and their CGs are randomly assigned to receive COPE plus their ongoing CHCPE services, or to continue receiving CHCPE services only., Outcomes: The primary outcome for older adults with dementia is functional independence; secondary outcomes are activity engagement, quality of life, and prevention or alleviation of neuropsychiatric symptoms. CG outcomes include perceived well-being and confidence in using activities to manage dementia symptoms. Translational outcomes include net financial benefit of COPE, and feasibility and acceptability of COPE implementation into the CHCPE. COPE has the potential to improve health-related outcomes while saving Medicaid waiver and state revenue-funded home care program costs nationwide., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: We sought to investigate the relationship between neuroticism and depression in an elderly cohort. In this paper, we describe the methods of an National Institute of Mental Health-NIMH-supported study and present findings among the cohort enrolled to date., Methods: We used the NEO Personality Inventory to assess neuroticism, and we employed several cognitive neuroscience-based measures to examine emotional control., Results: Compared with a group of 27 non-depressed older control subjects, 33 older depressed subjects scored higher on measures of state and trait anxiety and neuroticism. On our experimental neuroscience-based measures, depressed subjects endorsed more negative words compared with controls on an emotional characterization test. In addition, we found a significant group-by-congruency effect on an emotional interference test where subjects were asked to identify the face's emotional expression while ignoring the words "fear" or "happy" labeled across the face., Conclusion: Thus, in this preliminary work, we found significant differences in measures of neuroticism and emotional controls among older adults with and without depression.

Acute care hospitalization during or immediately following a Medicare home health care (HHC) episode is a major adverse outcome, but little has been published about HHC patient-level risk factors for hospitalization. The authors determined risk factors at HHC admission associated with subsequent acute care hospitalization in a nationally representative Medicare patient sample (N = 374,123). Hospitalization was measured using Medicare claims data; risk factors were measured using Outcome Assessment and Information Set data. Seventeen percent of sample members were hospitalized. Multivariate logistic regression analysis found that the most influential risk factors (all p < .001) were skin wound as primary HHC diagnosis, clinician-judged guarded rehabilitation prognosis, congestive heart failure as primary HHC diagnosis, presence of depressive symptoms, dyspnea severity, and Black, compared to White. HHC initiatives that minimize chronic condition exacerbations and actively treat depressive symptoms might help reduce Medicare patient hospitalizations. Unmeasured reasons for higher hospitalization rates among Black HHC patients deserve further investigation.

Purpose: To examine the cost structure of home health agencies by estimating an empirical cost function for those that are Medicare-certified, ten years following the implementation of prospective payment., Design and Methods: 2010 national Medicare cost report data for certified home health agencies were merged with case-mix information from the Outcome and Assessment Information Set (OASIS). We estimated a fully interacted (by tax status) hybrid cost function for 7,064 agencies and calculated marginal costs as percent of total costs for all variables., Results: The home health industry is dominated by for-profit agencies, which tend to be newer than the non-profit agencies and to have higher average costs per patient but lower costs per visit. For-profit agencies tend to have smaller scale operations and different cost structures, and are less likely to be affiliated with chains. Our estimates suggest diseconomies of scale, zero marginal cost for contracting with therapy workers, and a positive marginal cost for contracting with nurses, when controlling for quality., Implications: Our findings suggest that efficiencies may be achieved by promoting non-profit, smaller agencies, with fewer contract nursing staff. This conclusion should be tested further in future studies that address some of the limitations of our study.

Background: Many older adults become dependent in one or more activities of daily living (ADLs: dressing, bathing, transferring, eating, toileting) when hospitalized, and their prognosis after discharge is unclear., Objective: To develop a prognostic index to estimate one-year probabilities of recovery, dependence or death in older hospitalized patients who are discharged with incident ADL dependence., Design: Retrospective cohort study., Participants: 449 adults aged ≥ 70 years hospitalized for acute illness and discharged with incident ADL dependence., Main Measures: Potential predictors included demographics (age, sex, race, education, marital status), functional measures (ADL dependencies, instrumental activities of daily living [IADL] dependencies, walking ability), chronic conditions (e.g., congestive heart failure, dementia, cancer), reason for admission (e.g., neurologic, cardiovascular), and laboratory values (creatinine, albumin, hematocrit). Multinomial logistic regression was used to develop a prognostic index for estimating the probabilities of recovery, disability or death over 1 year. Discrimination of the index was assessed for each outcome based on the c statistic., Key Results: During the year following hospitalization, 36 % of patients recovered, 27 % remained dependent and 37 % died. Key predictors of recovery, dependence or death were age, sex, number of IADL dependencies 2 weeks prior to admission, number of ADL dependencies at discharge, dementia, cancer, number of other chronic conditions, reason for admission, and creatinine levels. The final prognostic index had good to excellent discrimination for all three outcomes based on the c statistic (recovery: 0.81, dependence: 0.72, death: 0.78)., Conclusions: This index accurately estimated the probabilities of recovery, dependence or death in adults aged 70 years or older who were discharged with incident disability following hospitalization. This tool may be useful in clinical settings to guide care discussions and inform decision-making related to post-hospitalization care.

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.

Type 2 diabetes mellitus is known to affect adults in racial and ethnic minority groups disproportionately. When diabetes mellitus-related symptoms lead to the need for skilled care in the community-dwelling Medicare population, physicians can order the Medicare home health care (HHC) benefit, and Medicare-certified home health agencies can deliver it. Little is known about the extent to which racial and ethnic disparities exist in types and patterns of HHC services delivered to Medicare beneficiaries with diabetes mellitus when they are approved for the Medicare HHC benefit. This was examined by comparing racial and ethnic groups in terms of measures of HHC service use in a nationally representative sample of Medicare HHC beneficiaries with a primary diagnosis of type 2 diabetes mellitus. Uniform clinical data from the Outcome and Assessment Information Set were linked with Medicare HHC claims for beneficiaries who received a complete episode of HHC in 2002. In the study sample (n=9,838), 62% of participants self-identified as white, 22% African American, 12% Hispanic, and 3% Asian. Nearly all (99%) participants in all racial and ethnic groups received skilled nursing services. Controlling for numerous sociodemographic and health-related covariates and geographic region of the country, African-American participants received fewer nurse visits per week and fewer visits per week from all clinical disciplines combined than whites (both P<.001), and Hispanic participants were less likely than whites to receive physical therapy (adjusted odds ratio (AOR)=0.640, 95% confidence interval (CI)=0.543-0.754, P<.001) or home health aide (AOR=0.716, 95% CI=0.582-0.880, P=.002) services. Lower use of skilled nursing and rehabilitation services by African Americans and of rehabilitation services by Hispanics warrant further clinical and research attention., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

This study evaluated the criterion validity of the Outcome and Assessment Instrument Set (OASIS) items that measure activities of daily living (ADLs), instrumental activities of daily living (IADLs), cognitive functioning, and depression. A convenience sample of patients (n = 203) from five home care agencies participated in the study. Patient OASIS items were compared to data collected using gold standard instruments. Correlations range from .44 to .69 for ADLs and .20 to .68 for IADLs. A correlation of .62 was found for cognitive functioning while correlations for depressive symptoms are .36 and .26. OASIS ADLs and cognitive status items are sufficiently valid, but the OASIS depression item is not sufficiently sensitive to the prevalence of these conditions.

This study determined factors associated with an increased risk of ending Medicare home health care because of hospitalization and examined specific types of and reasons for hospitalization. Sample members (N = 922) were followed from admission to discharge as they received home care from Ohio Medicare-certified home care agencies between December 1999 and March 2002. Potential patient-level risk factors were predisposing, enabling, or need variables, and an agency-level variable denoting hospital affiliation or free-standing status was examined as a second-level risk factor. Among those hospitalized (18.3%), more than 80.0% experienced emergency hospitalizations, mostly for acute exacerbations of chronic diseases. Statistically significant risk factors for hospitalization included dyspnea severity, functional disability level, skin or wound problems, diabetes, case mix score, and guarded rehabilitation prognosis. Home care agencies might reduce hospitalizations by using clinical prognosis as a key resource for team communication and by helping patients and families anticipate potential acute exacerbations of chronic diseases and manage these events at home.

The Outcomes and Assessment Information Set (OASIS) is now used extensively for regulatory, reimbursement, research, and clinical purposes in home health care. However, little is known about the interrater reliability of OASIS items based on assessments from home-health-agency clinicians. Therefore, we evaluated OASIS item interrater reliability among 88 patients from 21 agencies. Of 25 items studied, all except 2 had weighted kappa values of kappa > or = 0.60. We conclude that OASIS item interrater reliability was highly adequate in this study, but we recommend routine interrater-reliability evaluation by agencies to maximize the quality of OASIS data nationally.

From 1999 to 2003, the home health industry in the United States moved from an environment with extremely diverse data collection protocols and little or no dissemination of quality-related information, to an environment in which uniformly collected clinical data are transformed into information and then into publicly available reports using federally mandated quality indicators. This speed to action has raised many questions about the adequacy of home healthcare data and their use as quality-monitoring tools. This article summarizes current evidence about the scientific and clinical adequacy of data currently used to measure home healthcare quality and discusses roles of a variety of policy stakeholders in implementing and refining data, information, and quality indicators that are now the cornerstones of federal home healthcare quality policy. The scientific adequacy of Outcome and Assessment Information Set data is acceptable but bears routine monitoring and review; efforts should be made to develop home healthcare quality indicators sensitive to nursing interventions and published clinical practice guidelines for specific medical conditions; and policy stakeholders should collaborate to maximize the utility of home healthcare quality reports now disseminated to consumers, providers, and insurers.

Objectives: To determine whether hospital costs are higher in patients with lower functional status at admission, defined as dependence in one or more activities of daily living (ADLs), after adjustment for Medicare Diagnosis-Related Group (DRG) payments., Design: Prospective study., Setting: General medical service at a teaching hospital., Participants: One thousand six hundred twelve patients aged 70 and older., Measurements: The hospital cost of care for each patient was determined using a cost management information system, which allocates all hospital costs to individual patients., Results: Hospital costs were higher in patients dependent in ADLs on admission than in patients independent in ADLs on admission ($5,300 vs $4,060, P<.01). Mean hospital costs remained higher in ADL-dependent patients than in ADL-independent patients in an analysis that adjusted for DRG weight ($5,240 vs $4,140, P<.01), and in multivariate analyses adjusting for age, race, sex, Charlson comorbidity score, acute physiology and chronic health evaluation score, and admission from a nursing home as well as for DRG weight ($5,200 vs $4,220, P<.01). This difference represents a 23% (95% confidence interval=15-32%) higher cost to take care of older dependent patients., Conclusion: Hospital cost is higher in patients with worse ADL function, even after adjusting for DRG payments. If this finding is true in other hospitals, DRG-based payments provide hospitals a financial incentive to avoid patients dependent in ADLs and disadvantage hospitals with more patients dependent in ADLs.