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

OBJECTIVES: Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities. DESIGN: We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations. SETTING AND PARTICIPANTS: AL regulations and licensed AL communities across all 50 states in 2018. METHODS: We estimated the proportion of all licensed AL communities regulated by admission limitations and identified groups consisting of those that limit admission based on a health-related condition, specified behavior, mental health condition, and/or cognitive impairment as well as those that impose no limitations to admission. We also estimated the proportion of all licensed AL communities required to conduct assessments at time of admission. RESULTS: The largest group of ALs (29% nationally) is governed by regulations limiting the admission of persons with a health condition. The next largest group of AL communities (23.6%) limit admissions based on health, specified behavior, mental health conditions, and cognitive impairment. In contrast, 11.1% of licensed AL communities have no regulations restricting admissions. We also found that more than 8 of every 10 licensed communities were required to have residents complete a health assessment at admission, but less than half were required to complete a cognitive assessment. CONCLUSIONS AND IMPLICATIONS: The variation we observe implies that state agencies have created multiple licensure classifications that serve as a mechanism for sorting types of residents into settings based on their need (eg, health, mental health, cognitive). Although future research should investigate the implications of this regulatory diversity, the categories outlined here may be helpful to clinicians, consumers, and policy makers to better understand the options in their state and how various AL licensure classifications compare to one another.

Medicaid managed care in Iowa: Experiences of older adults and people with disabilities.

BACKGROUND: A growing number of states are turning to managed care arrangements to provide care to senior and disabled Medicaid beneficiaries. Despite their complex care needs, very little is known about the experience of these individuals in managed care. OBJECTIVE: To document experiences of a sample of aged and disabled Medicaid beneficiaries receiving long-term services and supports through managed care in Iowa and to assess whether these experiences changed over time. METHODS: A purposive sample of 49 aged and disabled beneficiaries enrolled in one of seven HCBS waivers in Iowa was recruited in 2017. Telephone surveys were conducted in 2017 and 2019. A conventional content analysis was used to generate themes, which were then ranked by frequency proportions. Thematic frequencies were compared across waves among repeat respondents. RESULTS: Content analysis yielded seven themes in the following areas: system navigation; service approvals; provider relations; customer service; case management; perception of Iowa's transition to managed care; and oversight. Concerns with service approvals was the most frequently reported theme and within this, issues related to changes in approved services or hours and quality of newly approved services comprised the largest number of references. Beneficiary concerns appeared to grow over time among respondents participating in both survey interview waves. CONCLUSION: The results of this study point to serious and persistent concerns related to access and quality of care under managed care for at least some HCBS waiver participants in Iowa, underscoring the need for a comprehensive evaluation of the program.

Preserving stroke care during the COVID-19 pandemic: Potential issues and solutions.

The coronavirus 2019 (COVID-19) pandemic requires drastic changes in allocation of resources, which can affect the delivery of stroke care, and many providers are seeking guidance. As caregivers, we are guided by 3 distinct principles that will occasionally conflict during the pandemic: (1) we must ensure the best care for those stricken with COVID-19, (2) we must provide excellent care and advocacy for patients with cerebrovascular disease and their families, and (3) we must advocate for the safety of health care personnel managing patients with stroke, with particular attention to those most vulnerable, including trainees. This descriptive review by a diverse group of experts in stroke care aims to provide advice by specifically addressing the potential impact of this pandemic on (1) the quality of the stroke care delivered, (2) ethical considerations in stroke care, (3) safety and logistic issues for providers of patients with stroke, and (4) stroke research. Our recommendations on these issues represent our best opinions given the available information, but are subject to revision as the situation related to the COVID-19 pandemic continues to evolve. We expect that ongoing emergent research will offer additional insights that will provide evidence that could prompt the modification or removal of some of these recommendations.

State Variability in the Prevalence and Healthcare Utilization of Assisted Living Residents with Dementia.

OBJECTIVES: Almost 1 million older and disabled adults who require long-term care reside in assisted living (AL), approximately 40% of whom have a diagnosis of Alzheimer's disease and related dementias (ADRD). States vary in their regulations specific to dementia care that may influence the presence of residents with ADRD in AL and their outcomes. The objectives of this study were to describe the state variability in the prevalence of ADRD among Medicare beneficiaries residing in larger (25+ bed) ALs and their healthcare utilization. DESIGN: Retrospective observational national study. PARTICIPANTS: National cohort of 293,336 Medicare fee-for-service enrollees residing in larger (25+ bed) ALs in 2016 and 2017 including 88,867 (30.3%) residents with ADRD. We compared this cohort's characteristics and healthcare utilization with that of individuals with ADRD who resided in nursing homes (NHs; n = 602,521) and the community (n = 2,074,420). METHODS: Medicare enrollment data, claims, and the NH Minimum Data Set were used to describe differences among ADRD patients in AL, NHs, and the community. We present rates of NH admission and hospitalization, by state, adjusting for age, sex, race, dual eligibility, and chronic conditions. RESULTS: The prevalence of ADRD among AL residents varied by state, ranging from 24% to 47%. In 2017, AL residents with ADRD had higher rates of NH admission than their community-dwelling counterparts (adjusted national average = 24%, ranging from 14% to 35% among states). AL residents with ADRD had higher rates of hospitalization (38%) than populations in either NHs (29%) or the community (34%), and ranged from 29% to 45% of residents among states. CONCLUSION: These findings have implications for states as they regulate AL and for healthcare professionals whose patients reside in AL. Future work is needed to understand specific elements of states' regulatory environments and local markets that may impact access and outcomes for this vulnerable population of residents with ADRD. J Am Geriatr Soc 68:1504-1511, 2020.

Strapped for Time or Stressed Out? Predictors of Work Interruption and Unmet Need for Workplace Support Among Informal Elder Caregivers.

OBJECTIVE: We evaluate whether strong associations between unmet need and work interruption observed among informal elder caregivers are explained by caregiver personal characteristics, caregiving situations, or diminished caregiver well-being. METHOD: We analyze a proprietary survey of informal elder caregivers conducted by a single large U.S. employer ( N = 642 caregivers). RESULTS: Unmet need was about twice as common among those experiencing mild (29.79%) or severe interruption (35.00%) relative to those who did not interrupt work (16.87%). Although caregiver characteristics and aspects of caregiving situation show links to either unmet need or work interruption specifically, the association between unmet need and work interruption was not explained by these factors, or by caregiver well-being. DISCUSSION: Needs-related work interruptions may arise by other workplace processes, such as organizational culture, that should be measured and tested explicitly by future research.

Impact of Stroke Call on the Stroke Neurology Workforce in the United States: Possible Challenges and Opportunities.

BACKGROUND: The Stroke & Vascular Neurology Section of the American Academy of Neurology was charged to identify challenges to the recruitment and retention of stroke neurologists and to make recommendations to address any identified problems. The Section initiated this effort by determining the impact of stroke on-call requirements as a barrier to the recruitment and retention of vascular neurologists. METHODS: This is a cross-sectional survey of a sample of US Neurologists providing acute stroke care. RESULTS: Of the 900 neurologists who were sent surveys, 313 (35%) responded. Of respondents from institutions providing stroke coverage, 71% indicated that general neurologists and 45% indicated that vascular neurologists provided that service. Of those taking stroke call, 36% agreed with the statement, "I spent too much time on stroke call," a perception that was less common among those who took less than 12-hour shifts (P < .0001); 21% who participated in stroke call were dissatisfied with their current job. Forty-six percent indicated that their stroke call duties contributed to their personal feeling of "burnout." CONCLUSIONS: Although the reasons are likely multifactorial, our survey of neurologists providing stroke care suggests that over-burdensome on-call responsibilities may be contributing to the vascular neurology workforce burnout and could be affecting recruitment and retention of vascular neurologists. Strategies to reduce the lifestyle impact of stroke call may help address this problem.

Leadership for Addressing Aging in America: The Health and Aging Policy Fellowship.

The Health and Aging Policy Fellows Program funded by The John A. Hartford Foundation and Atlantic Philanthropies trains future leaders to influence healthcare policy, systems, and program development in aging. Following a rigorous residential training in Washington, DC, Fellows establish placements of up to 1 year in the executive, legislative, or judicial branch of government, at a federal agency, state or community agency or committee, or with a nongovernmental organization. The 2016-2017 Fellows' activities represent a broad scope of work, including contributions to national and local policy priorities expected to build over time far beyond the core fellowship year.

The Increasing Use of Cannabis Among Older Americans: A Public Health Crisis or Viable Policy Alternative?

Cannabis use among older Americans is increasing. Although much of this growth has been attributed to the entry of a more tolerant baby boom cohort into older age, recent evidence suggests the pathways to cannabis are more complex. Some older persons have responded to changing social and legal environments and are increasingly likely to take cannabis recreationally. Other older persons are experiencing age-related health care needs, and some take cannabis for symptom management, as recommended by a medical doctor. Whether these pathways to recreational and medical cannabis are separate or somewhat tangled remains largely unknown. There have been few studies examining cannabis use among the growing population of Americans aged 65 and older. In this essay, we illuminate what is known about the intersection between cannabis and the aging American population. We review trends concerning cannabis use and apply the age-period-cohort paradigm to explicate varied pathways and outcomes. Then, after considering the public health problems posed by those who misuse or abuse cannabis, we turn our attention to how cannabis may be a viable policy alternative in terms of supporting the health and well-being of a substantial number of aging Americans. On the one hand, cannabis may be an effective substitute for prescription opioids and other misused medications; on the other hand, cannabis has emerged as an alternative for the undertreatment of pain at the end of life. As intriguing as these alternatives may be, policy makers must first address the need for empirically driven, representative research to advance the discourse.

Improving antipsychotic prescribing practices in nursing facilities: The role of surveyor methods and surveying agencies in upholding the Nursing Home Reform Act.

BACKGROUND: Inappropriate prescribing of antipsychotics is a longstanding challenge to providing high quality care in nursing facilities. The 1987 Nursing Home Reform Act (NHRA) had an initial impact in reducing inappropriate prescribing, but rates returned to pre-NHRA levels. While the recent Partnership to Improve Dementia Care in Nursing Homes (Partnership) initiative has been successful in reducing the prescribing of antipsychotics in skilled nursing facilities/nursing facilities (NF), it is not known how this guidance initiative impacted prescribing practices and other care processes concerning NF residents with dementia. OBJECTIVES: The objectives of this study were to explore surveyor observations of NF care practices subsequent to participation the Partnership guidance program and to use a social ecological framework to estimate how these observations were influenced by individual, organizational, and contextual factors. METHODS: A total of 320 NF surveyors responded to a 49-item questionnaire designed in collaboration with CMS officials and state surveying agency personnel, and distributed by state agency directors. Three outcome variables: measuring improvements in clinical care, deficiencies in clinical care, and falsification of records in response to the Partnership initiative, were created from survey responses. A four-level social ecological framework describing the NF surveyor's environment was used to identify potential influences on surveyors' care observations. Logistic regression was used to evaluate the relationship between environment and outcome variables. RESULTS: Surveyors observed both improvements in clinical care, including 80.6% reporting nursing facility providers responding to consultant pharmacists' recommendations, and deficits in clinical care in response to the Partnership initiative. Furthermore, 39.7% of surveyors observed a new, but false, diagnosis of psychosis (as defined by the surveyor). Surveyor characteristics and methods and surveying agency and culture were found to substantially impact the success of the Partnership initiative. The most distal level of the framework evaluated in this study, state contextual effects, was found not to impact care observations. CONCLUSIONS: There is substantial variation in surveyor observations of changes to clinical care in response to the Partnership guidance initiative. Further investigation is needed into the type and severity of falsification of records observed by nursing facility surveyors. When constructing interventions to care for residents in NFs, policymakers must consider the environment in which surveyors operate.

Policies to protect persons with dementia in assisted living: déjà vu all over again?

Continued growth in the number of individuals with dementia residing in assisted living (AL) raises concerns about their safety and protection. In this Forum, we review current AL practices relevant to residents with dementia and present a rationale for examining the government role in protecting these individuals within this context. Since public oversight of AL is currently a state prerogative, we assess states' regulatory activity across 3 domains closely related to safety and protection of persons with dementia: environmental features, staffing, and use of chemical restraints. We then step back to consider the state policymaking environment and assess the feasibility of developing a minimum standard of regulations from one state to the next. This Forum concludes with a historical comparison between the contemporary AL market and the nursing home care market prior to the Nursing Home Reform Act of 1987, and we discuss how an increased amount of federal interest could improve existing state efforts to protect persons with dementia residing in AL.

Chiropractic episodes and the co-occurrence of chiropractic and health services use among older Medicare beneficiaries.

OBJECTIVE: The purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine. METHODS: Medicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample. RESULTS: There were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9% to 10.9% over the 17-year period. CONCLUSION: Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

A prospective cohort study of long-term cognitive changes in older Medicare beneficiaries.

BACKGROUND: Promoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function. METHODS: We conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were ≥ 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests. RESULTS: Mean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6%, 54.9%, and 52.3% declining and 25.4%, 20.8%, and 22.9% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status. CONCLUSIONS: In addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries.

BACKGROUND: Most prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines. METHODS: The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop. RESULTS: The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline. CONCLUSIONS: Both the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.

Translating collaborative models of mental health care for older adults: using Iowa's experience to inform national efforts.

The Patient Protection and Affordable Care Act supports the translation of collaborative models of mental health care, but how the act will affect older adults remains unclear. The authors examined a sample of older Medicare beneficiaries and evaluated how individual characteristics, local service supplies, and other contextual features corresponded with the identification of older persons with psychiatric diagnoses and their access to specialty mental health care providers. Older adults presented a variety of psychiatric disorders, and their access and use of specialty mental health care related to age; sex; diagnosis; supply of mental health, health, and long-term care providers; and whether an older person lived in a rural area. Translation of collaborative models should consider a range of psychiatric conditions, adjust for varying local provider supplies, and consider the challenges in establishing collaborative care within rural areas.