Perceptions of the Role of Living Alone in Providing Services to Patients With Cognitive Impairment.

Importance: The potential role of living alone in either facilitating or hampering access to and use of services for older adults with cognitive impairment is largely unknown. Specifically, it is critical to understand directly from health care and social services professionals how living alone creates barriers to the access and use of supportive health care and social services for racially and ethnically diverse patients with cognitive impairment. Objective: To identify the potential role of living alone in the access and use of health care and social services for diverse patients with cognitive impairment by investigating professionals' perceptions of caring for such patients who live alone in comparison with counterparts living with others. Design, Setting, and Participants: This qualitative study of 76 clinicians, social workers, and other professionals used semistructured interviews conducted between February 8, 2021, and June 8, 2022, with purposively sampled professionals providing services to diverse patients with cognitive impairment in Michigan, California, and Texas. Main Outcomes and Measures: Clinicians, social workers, and other professionals compared serving patients with cognitive impairment and living alone vs counterparts living with others. An inductive content analysis was used to analyze the interview transcripts. Results: A total of 76 professionals were interviewed (mean [SD] age, 49.3 [12.7] years); 59 were female (77.6%), 8 were Black or African American (11%), and 35 were White (46%). Participants included physicians, nurses, social workers, and home-care aides, for a total of 20 professions. Participants elucidated specific factors that made serving older adults living alone with cognitive impairment more challenging than serving counterparts living with others (eg, lacking an advocate, incomplete medical history, requiring difficult interventions), as well as factors associated with increased concerns when caring for older adults living alone with cognitive impairment, such as isolation and a crisis-dominated health care system. Participants also identified reasons for systematic unmet needs of older adults living alone with cognitive impairment for essential health care and social services, including policies limiting access and use to public home-care aides. Conclusions and Relevance: In this qualitative study of professionals' perspectives, findings suggest that living alone is a social determinant of health among patients with cognitive impairment owing to substantial barriers in access to services. Results raised considerable concerns about safety because the US health care system is not well equipped to address the unique needs of older adults living alone with cognitive impairment.

Use of Home-Based Clinical Care and Long-Term Services and Supports Among Homebound Older Adults.

OBJECTIVES: Describe use of home-based clinical care and home-based long-term services and supports (LTSS) using a nationally representative sample of homebound older Medicare beneficiaries. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Homebound, community-dwelling fee-for-service Medicare beneficiaries participating in the 2015 National Health and Aging Trends Study (n = 974). METHODS: Use of home-based clinical care [ie, home-based medical care, skilled home health services, other home-based care (eg, podiatry)] was identified using Medicare claims. Use of home-based LTSS (ie, assistive devices, home modification, paid care, ≥40 hours/wk of family caregiving, transportation assistance, senior housing, home-delivered meals) was identified via self or proxy report. Latent class analysis was used to characterize patterns of use of home-based clinical care and LTSS. RESULTS: Approximately 30% of homebound participants received any home-based clinical care and about 80% received any home-based LTSS. Latent class analysis identified 3 distinct patterns of service use: class 1, High Clinical with LTSS (8.9%); class 2, Home Health Only with LTSS (44.5%); and class 3, Low Care and Services (46.6% homebound). Class 1 received extensive home-based clinical care, but their use of LTSS did not meaningfully differ from class 2. Class 3 received little home-based care of any kind. CONCLUSIONS AND IMPLICATIONS: Although home-based clinical care and LTSS utilization was common among the homebound, no single group received high levels of all care types. Many who likely need and could benefit from such services do not receive home-based support. Additional work focused on better understanding potential barriers to accessing these services and integrating home-based clinical care services with LTSS is needed.

Severe neighborhood deprivation and nursing home staffing in the United States.

BACKGROUND: Low nursing home staffing in the United States is a growing safety concern. Socioeconomic deprivation in the local areas surrounding a nursing home may be a barrier to improving staffing rates but has been poorly studied. Thus, the objective of this paper was to assess the relationship between neighborhood deprivation and nursing home staffing in the United States. METHODS: This cross-sectional study used 2018 daily payroll-based staffing records and address data for 12,609 nursing homes in the United States linked with resident assessment data. Our primary exposure of interest was severe economic deprivation at the census block group (neighborhood) level, defined as an area deprivation index score ≥85/100. The primary outcome was hours worked per resident-day among nursing home employees providing direct resident care. Marginal linear regression models and generalized estimating equations with robust sandwich-type standard errors were used to estimate associations between severe neighborhood deprivation and staffing rates. RESULTS: Compared to less deprived neighborhoods, unadjusted staffing rates in facilities located within severely deprived neighborhoods were 38% lower for physical and occupational therapists, 30% lower for registered nurses (RNs), and 5% lower for certified nursing assistants. No disparities in licensed practical nurse (LPN) staffing were observed. In models with state-level and rurality fixed effects and clustered on the county, a similar pattern of disparities was observed. Specifically, RN staffing per 100 resident-days was significantly lower in facilities located within severely deprived neighborhoods as compared to those in less deprived areas (mean difference: 5.6 fewer hours, 95% confidence interval [CI] 4.2-6.9). Disparities of lower magnitude were observed for other clinical disciplines except for LPNs. CONCLUSIONS: Significant staffing disparities were observed within facilities located in severely deprived neighborhoods. Targeted interventions, including workforce recruitment and retention efforts, may be needed to improve staffing levels for nursing homes in deprived neighborhoods.

"It Makes You Feel Good to Help!": An Exploratory Study of the Experience of Peer Mentoring in Long-Term Care.

Social isolation and loneliness in long-term care settings are a growing concern. Drawing on concepts of social citizenship, we developed a peer mentoring program in which resident mentors and volunteers formed a team, met weekly for training, and paired up to visit isolated residents. In this article, we explore the experiences of the resident mentors. As part of a larger mixed-methods study conducted in 10 sites in Canada, we interviewed mentors (n = 48) and analysed data using inductive thematic analysis. We identified three inter-related themes: Helping others, helping ourselves described the personal benefits experienced through adopting a helping role; Building a bigger social world encapsulated new connections with those visited, and; Facing challenges, learning together described how mentors dealt with challenges as a team. Our findings suggest that a structured approach to mentoring benefits residents and helps them feel confident taking on a role supporting their isolated peers.

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.

Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis.

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.

The Impact of Peer Mentoring on Loneliness, Depression, and Social Engagement in Long-Term Care.

Loneliness, depression, and social isolation are common among people living in long-term care homes, despite the activities provided. We examined the impact of a new peer mentoring program called Java Mentorship on mentees' loneliness, depression, and social engagement, and described their perceptions of the visits. We conducted a mixed-methods approach in 10 homes in Ontario, Canada, and enrolled residents as mentees (n = 74). We used quantitative surveys and qualitative interviews to understand their experience. After 6 months, mentees (n = 43) showed a 30% reduction in depression (p = .02, d = .76), a 12% reduction in loneliness (p = .02, d = .76), and a 60% increase in the number of monthly programs attended (p = .01, d = .37), with small-to-medium effect sizes. The analysis of mentee's interviews revealed positive perceptions. This program offers an innovative, nonpharmacological alternative to the treatment of loneliness and depression.

'It makes life worthwhile!' Peer mentoring in long-term care-a feasibility study.

Objectives: Loneliness and depression are of increasing concern in long-term care homes made more urgent by viral outbreak isolation protocols. An innovative program called Java Mentorship was developed that engaged community volunteers and resident volunteers (mentors) as a team. The team met weekly, received education, and provided visits and guidance in pairs to socially disengaged residents (mentees). The purpose of this study was to assess the feasibility of conducting a larger study.Method: We conducted a mixed-methods pre-post study to evaluate the program. We collected feasibility data associated with the program implementation, including assessment of the sample and ability to recruit; procedures for data collection; retention, program adherence and acceptability; and residents' responses including loneliness, depression, purpose in life, social identity and sense of belonging outcomes. We enrolled community mentors (n = 65), resident mentors (n = 48) staff facilitators (n = 24) and mentees (n = 74) in 10 Canadian sites.Results: Most feasibility objectives were met, and adherence and acceptability were high. Some resource challenges and low retention rates among resident mentors were noted. We found a 29% reduction in depression scores (p = .048; d = .30) and 15% reduction in loneliness scores (p = .014; d = .23). Purpose in life, social identity and sense of belonging were unchanged. Interviews among participants indicated high acceptability and positive perceptions of the program.Conclusion: The study findings reveal a potential role for mentorship as a viable approach to reducing loneliness and depression in long-term care settings and lay the groundwork for future research.

The Demographics and Economics of Direct Care Staff Highlight Their Vulnerabilities Amidst the COVID-19 Pandemic.

An estimated 3.5 million direct care staff working in facilities and people's homes play a critical role during the COVID-19 pandemic. They allow vulnerable care recipients to stay at home and they provide necessary help in facilities. Direct care staff, on average, have decades of experience, often have certifications and licenses, and many have at least some college education to help them perform the myriad of responsibilities to properly care for care recipients. Yet, they are at heightened health and financial risks. They often receive low wages, limited benefits, and have few financial resources to fall back on when they get sick themselves and can no longer work. Furthermore, most direct care staff are parents with children in the house and almost one-fourth are single parents. If they fall ill, both they and their families are put into physical and financial risk.

Beyond Functional Support: The Range Of Health-Related Tasks Performed In The Home By Paid Caregivers In New York.

Paid caregivers (for example, home health aides and personal care attendants) are formally tasked with helping older adults with functional impairment meet their basic needs at home. This study used thirty semistructured interviews with dyads of patients or their proxies and their paid caregivers in New York City to understand the range of health-related tasks that paid caregivers perform in the home and determine whether these tasks are taught in the New York State Department of Health's curriculum. We found that patients, proxies, and paid caregivers all reported that paid caregivers performed a wide range of health-related tasks that were often not part of their formal training. Creating clear competencies for paid caregivers that reflect the full breadth of health-related tasks they may perform in the home could help maximize the positive impact of the paid caregiver workforce on the lives of patients living at home with functional impairment.

Home And Community-Based Workforce For Patients With Serious Illness Requires Support To Meet Growing Needs.

Home health and personal care aides are one of the largest groups of health care workers in the US, with nearly three million people providing direct care for people with serious illness living in the community. These home care workers face challenges in recruitment, training, retention, and regulation, and there is a lack of data and research to support evidence-based policy change. Personal care aides receive little formal training, and they experience low pay and a lack of respect for the skill required for their jobs. High turnover and occupational injury rates are widely reported. There is little research on the factors associated with higher-quality home care, the extent to which worker training affects client outcomes, and how regulations affect access to and quality of home care. Health care leaders should seek to fill these gaps in knowledge, support the establishment of training standards and programs, implement Medicaid reimbursement strategies that incentivize improvements in pay and working conditions, reform regulations that now prevent the full utilization of home care workers, and create sustainable career pathways in home care policies.

The Future of the Home Care Workforce: Training and Supporting Aides as Members of Home-Based Care Teams.

Home health, home care, and personal care aides provide most of the paid hands-on care delivered to seriously ill, functionally impaired individuals in their homes, assisted living, and other noninstitutional settings. This workforce delivers personal care, assistance with activities of daily living, and emotional support to their patients. They are often the eyes and ears of the health system, observing subtle changes in condition that can provide important information for clinical decision making and therapeutic intervention. Despite this fact, the growing number of team-based home care initiatives have failed to incorporate this workforce into their programs. Barriers to inclusion of aides into teams include a basic lack of value and understanding on the part of clinical team members and society in general of the complex tasks that these caregivers perform, inadequate investments in training and education of this workforce to develop their knowledge and competencies, and variation in state delegation laws that limit the scope of practice and consequently the ability of aides to work effectively in teams and to advance in their careers. Building on the few programs that have successfully included aides as key members of home care teams, federal and state policymakers, educators, and health systems and providers should standardize competency-based training requirements, expand nurse delegation consistently across states, and support evaluation, dissemination, and replication of successful programs. J Am Geriatr Soc 67:S444-S448, 2019.

Person-Centered Care as Facilitated by Kansas' PEAK 2.0 Medicaid Pay-for-Performance Program and Nursing Home Resident Clinical Outcomes.

PURPOSE OF THE STUDY: Person-centered care (PCC) is intended to improve nursing home residents' quality of life, but the closer bonds it engenders between residents and staff may also facilitate improvements to residents' clinical health. Findings on whether adoption ameliorates resident clinical outcomes are conflicting, with some evidence of harm as well as benefit. To provide clearer evidence, the present study made use of Kansas' PEAK 2.0 Medicaid pay-for-performance (P4P) program, which incents the adoption of PCC. The program is distinctive in training facilities' staff on adopting PCC through a series of well-defined stages and providing regular feedback about their progress. DESIGN AND METHODS: A retrospective cohort study was performed with 349 Kansas facilities spread across several well-defined PCC adoption stages, ranging from nonadoption to comprehensive adoption. The outcomes were thirteen 2014-2016 Nursing Home Compare long-stay resident clinical measures and a composite measure incorporating only nonimputed data for those 13 outcomes. Observed facility demographic differences were controlled for with propensity score adjustment. Treatment effect analyses were run with each outcome, with the predictor variable of program stage. RESULTS: Seven of the 13 clinical measures plus the composite measure indicated better health for residents in homes at higher program stages, relative to those in nonparticipating homes, including a 49% lower prevalence of major depressive symptoms in strongly adopting facilities. IMPLICATIONS: The findings suggest that greater PCC adoption through PEAK participation is associated with better quality of care. Policymakers in other states may want to consider implementing a program modeled on PEAK 2.0.

The housing challenges of low-income older adults and the role of federal policy.

Adequate housing is critical for low-income older adults, who face affordability and accessibility challenges that affect their quality of life, health, and ability to live independently in their communities. This article examines the federal policy role in meeting the housing and housing-related needs of the low-income elderly population, which is expected to grow as a proportion of all older adults over the next two decades. The availability of publicly subsidized units and vouchers is woefully inadequate to assist the current low-income elderly population in need of rental assistance. While access to affordable and accessible housing options has been a growing challenge for several decades, the Trump administration and Republican-majority Congress has an agenda and specific budgetary, administrative, and legislative proposals that would worsen the housing situation today and into the future. Population aging combined with a lack of investment in affordable senior housing and related programs over the last two decades requires a call to action for stakeholders in the public and private sectors to jointly develop a comprehensive national senior housing policy agenda and implementation strategy.