Interorganizational Context When Implementing Multisector Partnered Programs: A Qualitative Analysis of Veteran Directed Care.

As the number of Veterans enrolled in the Veterans Health Administration (VHA) and at risk for needing Long Term Services and Supports increases, VHA is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program. VDC is a multi-sector program implemented as a collaboration between individual VHA medical centers (VAMCs) and Aging and Disability Network Agencies (ADNAs), entities that sit outside the VHA. Factors that affect establishment of effective multi-sector programs such as VDC are poorly understood, limiting ability to effectively deliver and scale programs. We conducted a qualitative study to describe factors affecting the interorganizational implementation context of VDC. Using constructs from the Consolidated Framework for Implementation Research (CFIR), we interviewed VDC coordinators from seven different VAMC-ADNA partnerships that initiated the VDC program between 2017 and 2018. We identified eight CFIR determinants which manifested similarly for the VAMCs and ADNAs: evidence strength and quality, relative advantage, adaptability, tension for change, access to knowledge and information, self-efficacy; engaging, and champions. We identified three CFIR determinants that varied dramatically across VAMCs and ADNAs: available resources, implementation climate, and relative priority. Our results suggest that interorganizational context plays a critical and dynamic role within multi-sector collaborations.

Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community.

The United States Department of Veterans Affairs (VA) is facing pressures to rebalance its long-term care system. Using VA administrative data from 2004-2011, we describe changes in the VA's nursing homes (called Community Living Centers [CLCs]) following enactment of directives intended to shift CLCs' focus from providing long-term custodial care to short-term rehabilitative and post-acute care, with safe and timely discharge to the community. However, a concurrent VA hospice and palliative care expansion resulted in an increase in hospice stays, the most notable change in type of stay during this time period. Nevertheless, outcomes for Veterans with non-hospice short and long stays, such as successful discharge to the community, improved. We discuss the implications of our results for simultaneous implementation of two initiatives in VA CLCs.

Individualized Music Program is Associated with Improved Outcomes for U.S. Nursing Home Residents with Dementia.

OBJECTIVES: The objective of this study was to compare resident outcomes before and after implementation of an individualized music program, MUSIC & MEMORY (M&M), designed to address the behavioral and psychological symptoms associated with dementia (BPSD). SETTING: 98 nursing homes trained in the M&M program during 2013 and 98 matched-pair comparisons. PARTICIPANTS: Long-stay residents with Alzheimer's disease and related dementias (ADRD) residing in M&M participating facilities (N = 12,905) and comparison facilities (N = 12,811) during 2012-2013. INTERVENTION: M&M is a facility-level quality improvement program that provides residents with music specific to their personal histories and preferences. MEASUREMENTS: Discontinuation of anxiolytic and antipsychotic medications, and reductions in behavioral problems and depressed mood in 2012 (pre-intervention) and 2013 (intervention), calculated using Minimum Data Set (MDS) assessments. RESULTS: The proportion of residents who discontinued antipsychotic medication use over a 6-month period increased from 17.6% to 20.1% among M&M facilities, while remaining stable among comparison facilities (15.9% to 15.2%). The same trend was observed for anxiolytic medications: Discontinuation of anxiolytics increased in M&M facilities (23.5% to 24.4%), while decreasing among comparison facilities (24.8% to 20.0%). M&M facilities also demonstrated increased rates of reduction in behavioral problems (50.9% to 56.5%) versus comparison facilities (55.8% to 55.9%). No differences were observed for depressed mood. CONCLUSIONS: These results offer the first evidence that the M&M individualized music program is associated with reductions in antipsychotic medication use, anxiolytic medication use, and BPSD symptoms among long-stay nursing home residents with ADRD.

Local Medicaid home- and community-based services spending and nursing home admissions of younger adults.

We used fixed-effect models to examine the relationship between local spending on home- and community-based services (HCBSs) for cash-assisted Medicaid-only disabled (CAMOD) adults and younger adult admissions to nursing homes in the United States during 2001 through 2008, with control for facility and market characteristics and secular trends. We found that increased CAMOD Medicaid HCBS spending at the local level is associated with decreased admissions of younger adults to nursing homes. Our findings suggest that states' efforts to expand HCBS for this population should continue.

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.

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 semistructured 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.

Do Medicaid incentive payments boost quality? Florida's direct care staffing adjustment program.

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents--the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.

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.

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.

'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.

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.

Connecting policy to licensed assisted living communities, introducing health services regulatory analysis.

OBJECTIVE: To document dementia-relevant state assisted living regulations and their changes over time as they pertain to licensed care settings. DATA SOURCES: For all states, current directories of licensed assisted living communities and state regulations for each year, 2007-2018, were obtained from state agency websites and Nexis Uni, respectively. STUDY DESIGN: We identified multiple types of regulatory classifications for each state and documented the presence or absence of specific dementia care provisions in the regulations for each type by study year. Maps and summary statistics were used to compare results to previous research and document change longitudinally. DATA COLLECTION/EXTRACTION METHODS: We used a policy analysis approach to connect communities listed in directories to applicable regulatory text. Then, we employed policy surveillance and question-based coding to record the presence or absence of specific policies for each classification and study year. PRINCIPAL FINDINGS: Our team empirically documented provisions requiring dementia-specific training for administrators and direct care staff, and cognitive impairment screening for each study year. We found that 23 states added one or more of these requirements for one or more license types, but the states that had these provisions for all types of licensed assisted living declined from four to two. CONCLUSIONS: We identified significant, previously undocumented, within-state policy variation for assisted living licensed settings between 2007 and 2018. Using the regulatory classification instead of the state as the unit of analysis revealed that many policy adoptions were limited to dementia-designated settings. This suggests that people living with dementia in general assisted living are not afforded the same protections. We call our approach health services regulatory analysis and argue that it has the potential to identify gaps in existing policies, an important endeavor for health services research in assisted living and other care settings.

Users Of Veteran-Directed Care And Other Purchased Care Have Similar Hospital Use And Costs Over Time.

The Veteran-Directed Care (VDC) program facilitates independent community living among adults with multiple chronic conditions and functional limitations. Family caregivers value the choice and flexibility afforded by VDC, but rigorous evidence to support its impact on health care costs and use is needed. We identified veterans enrolled in VDC in fiscal year 2017 and investigated differences in hospital admissions and costs after initial receipt of VDC services. We compared VDC service recipients to a matched comparison group of veterans receiving homemaker or home health aide, home respite, and adult day health care services and found similar decreases in hospital use and costs from before to after enrollment in the groups. Further investigation into trends of nursing home use, identification of veterans most likely to benefit from VDC, and relative costs of operating VDC versus other purchased care programs is needed, but our results suggest that VDC remains a valuable option for supporting veterans and caregivers.

Are dual eligibles admitted to poorer quality skilled nursing facilities?

BACKGROUND: Dual eligibles, persons who qualify for both Medicare and Medicaid coverage, often receive poorer quality care relative to other Medicare beneficiaries. OBJECTIVES: To determine whether dual eligibles are discharged to lower quality post-acute skilled nursing facilities (SNFs) compared with Medicare-only beneficiaries. RESEARCH DESIGN: Following the random utility maximization model, we specified a discharge function using a conditional logit model and tested how this discharge rule varied by dual-eligibility status. SUBJECTS: A total of 692,875 Medicare fee-for-service patients (22% duals) who were discharged for Medicare paid SNF care between July 2004 and June 2005. MEASURES: Medicare enrollment and the Medicaid Analytic Extract files were used to determine dual eligibility. The proportion of Medicaid patients and nursing staff characteristics provided measures of SNF quality. RESULTS: Duals are more likely to be discharged to SNFs with a higher share of Medicaid patients and fewer nurses. These results are robust to estimation with an alternative subsample of patients based on primary diagnoses, propensity of being dual eligible, and likelihood of remaining in the nursing home. CONCLUSIONS: Disparities exist in access to quality SNF care for duals. Strategies to improve discharge planning processes are required to redirect patients to higher quality providers, regardless of Medicaid eligibility.

Providing more home-delivered meals is one way to keep older adults with low care needs out of nursing homes.

Programs that help older adults live independently in the community can also deliver net savings to states on the costs of long-term supports and services. We estimate that if all states had increased by 1 percent the number of adults age sixty-five or older who received home-delivered meals in 2009 under Title III of the Older Americans Act, total annual savings to states' Medicaid programs could have exceeded $109 million. The projected savings primarily reflect decreased Medicaid spending for an estimated 1,722 older adults with low care needs who would no longer require nursing home care--instead, they could remain at home, sustained by home-delivered meals. Twenty-six states could have realized net savings in 2009 from the expansion of their home-delivered meals programs, while twenty-two states would have incurred net costs. Programs such as home-delivered meals have the potential to provide substantial savings to some states' Medicaid programs.