Barriers and Facilitators to Home- and Community-Based Services Access for Persons With Dementia and Their Caregivers.

OBJECTIVES: The United States has seen increasing shifts toward home- and community-based services (HCBS) in place of institutional care for long-term services and supports. However, research has neglected to assess whether these shifts have improved access to HCBS for persons with dementia. This paper identifies HCBS access barriers and facilitators, and discusses how barriers contribute to disparities for persons with dementia living in rural areas and exacerbate disparities for minoritized populations. METHODS: We analyzed qualitative data from 35 in-depth interviews. Interviews were held with stakeholders in the HCBS ecosystem, including Medicaid administrators, advocates for persons with dementia and caregivers, and HCBS providers. RESULTS: Barriers to HCBS access for persons with dementia range from community and infrastructure barriers (e.g., clinicians and cultural differences), to interpersonal and individual-level barriers (e.g., caregivers, awareness, and attitudes). These barriers affect the health and quality of life for persons with dementia and may affect whether individuals can remain in their home or community. Facilitators included a range of more comprehensive and dementia-attuned practices and services in health care, technology, recognition and support for family caregivers, and culturally competent and linguistically accessible education and services. DISCUSSION: System refinements, such as incentivizing cognitive screening, can improve detection and increase access to HCBS. Disparities in HCBS access experienced by minoritized persons with dementia may be addressed through culturally competent awareness campaigns and policies that recognize the necessity of familial caregivers in supporting persons with dementia. These findings can inform efforts to ensure more equitable access to HCBS, improve dementia competence, and reduce disparities.

Low Exposure to Home- and Community-Based Services Among U.S. Adults: Cause for Concern?

Home- and community-based services (HCBS) facilitate community living for older adults and persons with disabilities, but limited awareness of HCBS is a significant barrier to access. Social exposure is one potential conduit for HCBS knowledge. To understand the general population's social exposure to HCBS-that is, knowing someone who has used HCBS (including one's self)-we fielded a survey item with a nationally representative panel of U.S. adults. An estimated 53% of U.S. adults reported not knowing anyone who had used HCBS. Exposure rates were low across specific HCBS types (6%-28%). Women had greater exposure than men for eight of the 11 HCBS. We also found differences by age, racial/ethnic identity, rurality, education, and income. Increasing the general public's awareness of HCBS may facilitate access when services are needed, enhance readiness for aging in place, and increase the visibility and inclusion of older adults, persons with disabilities, and caregivers.

Licensed and unlicensed cannabis outlets in Los Angeles County: the potential implications of location for social equity.

BACKGROUND: Cannabis social equity programs intend to redress inequities experienced by low income and Black, Indigenous, and People of Color (BIPOC) during cannabis prohibition in the United States. In Los Angeles County (LA), the approach is to increase cannabis outlet licensure and employment for low income and BIPOC communities. Monitoring locations of both licensed and unlicensed outlets over time is critical to informing how local social equity programs may affect communities. METHODS: We identified locations of licensed and unlicensed cannabis outlets in LA, from February to April 2019 and again from March to April 2020, and calculated the number and type of outlets by socio-demographic characteristics of census tracts (race/ethnicity, poverty, education, unemployment) using the 2013-2017 American Community Survey 5-year estimates. RESULTS: Licensed outlets increased in LA from 162 in 2019 to 195 in 2020; unlicensed outlets decreased from 286 to 137 over the same time period. In 2020, more licensed outlets were in tracts with majority white residents and adults with at least a bachelor's degree; fewer licensed outlets were in tracts with larger Latinx or Black populations, whereas 71% of unlicensed outlets in 2020 were in low-income tracts, and more unlicensed outlets were in predominately Latinx tracts, high poverty and high unemployment tracts, and tracts with more single female-headed households. CONCLUSIONS: Neighborhood-level analyses are an important first step, but more data are needed for comprehensive evaluations of social equity programs-from individual businesses to the communities living nearby-to understand the impacts on low income and BIPOC populations.

Standardized assessment of medication reconciliation in post-acute care.

BACKGROUND: Medication reconciliation (MR) facilitates safety during transitions of care, which occur frequently across post-acute care (PAC) settings. Under the intent of the IMPACT Act of 2014, the Centers for Medicare & Medicaid Services contracted with the RAND Corporation to develop and test standardized assessment data elements (SADEs) that assess the MR process. METHODS: We employed an iterative process that incorporated stakeholder input and three rounds of testing to identify, refine, and evaluate MR SADEs. Testing took place in 186 PAC sites (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 skilled nursing facilities). There were 2951 patients in the final test. Novel MR SADEs, based on the Joint Commission's framework, were refined. The final SADEs assessed whether: patient was taking high-risk medications; an indication was noted for each medication class; discrepancies were identified; patient or family/caregiver was involved in addressing discrepancies; discrepancies were communicated to physician (or designee) within 24 h; recommended physician actions regarding discrepancies were implemented within 24 h after physician response; and the reconciled list was communicated to patient, prescriber, and/or pharmacy. Two assessors per facility collected data for each patient. Analyses described completion time, data missingness, and interrater reliability, as well as feedback on assessor burden. RESULTS: Time to complete the MR SADEs was 3.2 min. Missing data were <5%. Interrater reliability was moderate to high (κ: 0.42 [whether a reconciled list was communicated to prescribers] to 0.89 [identifying patients taking hypoglycemics]). For identifying high-risk medication classes, interrater reliability was high (κ: 0.72-0.89). There were minimal differences by setting. CONCLUSIONS: This is the first set of MR SADEs that have been assessed across the PAC settings. Results demonstrate feasibility, based on missing data and completion time, and moderate to strong reliability, based on interrater comparisons, of assessing MR.

Loneliness and multiple health domains: associations among emerging adults.

Emerging adults (18-25 years), particularly racially/ethnically diverse and sexual and gender minority populations, may experience loneliness following major life transitions. How loneliness relates to health and health disparities during this developmental period is not well understood. We examine associations of loneliness with physical (self-rated health), behavioral (alcohol/marijuana consequences; nicotine dependence), and health behavior outcomes (weekday and weekend sleep; trouble sleeping), and investigate moderating effects by sex, race/ethnicity, and sexual/gender minority (SGM) status. Adjusted models using cross-sectional data from 2,534 emerging adults, predominantly in California, examined associations between loneliness and each outcome and tested interactions of loneliness with sex, race/ethnicity, and SGM status. Higher loneliness was significantly associated with worse self-rated health, higher marijuana consequences, less weekday sleep, and greater odds of feeling bothered by trouble sleeping. None of the interactions were significant. Findings suggest that interventions to reduce loneliness may help promote healthy development among emerging adults across subgroups.

Perceived impacts of a Medicaid rebalancing initiative to increase home- and community-based services.

OBJECTIVE: To assess governmental and nongovernmental stakeholders' perceived impacts of a Medicaid home- and community-based services (HCBS) rebalancing initiative, the Balancing Incentive Program (BIP). DATA SOURCES: Governmental stakeholders (Medicaid administrators) and nongovernmental stakeholders (service providers and consumer advocates) (n = 30) from eight states that participated in BIP. STUDY DESIGN: We conducted key informant interviews. DATA COLLECTION: Interviews followed a semi-structured guide and were professionally transcribed. We thematically coded transcripts using an iterative codebook with a priori and emergent codes. PRINCIPAL FINDINGS: Stakeholders reported that BIP participation had a range of impacts on the HCBS ecosystem, often beyond the mandated structural reforms. BIP activities were believed to have changed the culture of HCBS in some states, for example, at the level of state administration or in the provision of HCBS to consumers. Stakeholders also described significant improvements in cross-stakeholder relationships and communication, for example, in the context of troubleshooting consumers' unmet needs or improvements in the states' responsiveness to providers' inquiries. Stakeholders believed that within-state data harmonization undertaken through Core Standardized Assessment (CSA) was a positive impact of BIP, particularly with regard to its utility for administrative data, care planning, and patient-centeredness. Two stakeholders also voiced concerns regarding the validity of spending-based rebalancing metrics. The impacts that stakeholders attributed to BIP may help create a more sustained rebalancing environment through their changes to the ecosystem, including infrastructure upgrades, data harmonization, collaboration across stakeholders and agencies, more patient-centeredness, and greater recognition of HCBS. CONCLUSIONS: Our findings highlight additional BIP impacts to monitor over the longer term and to consider in evaluations of future rebalancing efforts. Some potential impacts of BIP are more readily quantified (e.g., HCBS spending), while others are less likely to be formally assessed (e.g., improved stakeholder cooperation). These latter impacts are likely instrumental to future rebalancing efforts.

The Foreclosure Crisis, Community Change, and the Cognitive Health of Older Adults.

OBJECTIVES: While home foreclosures are often thought of as a household-level event, the consequences may be far-reaching, and spill over to the broader community. Older adults, in particular, could be affected by the spiral of community changes that result from foreclosures, but we know very little about how the foreclosure crisis is related to older adult health, in particular cognition. METHOD: This article uses growth curve models and data from the Health and Retirement Study matched to Census and county-level foreclosure data to examine whether community foreclosures are related to older adults' cognitive health and the mechanisms responsible. RESULTS: We find that higher rates of county-level foreclosures are associated with a faster decline in individual cognition at older ages. Although we examined an extensive number of individual and community mechanisms, including individual housing wealth and depressive symptoms, community structural factors, social factors, and perceptions of physical disorder and cohesion, none of the mechanisms examined here explained this relationship. DISCUSSION: This study shows that the adverse consequences of home foreclosures spill over to the local community, with implications for the cognitive health of older adults.

Factors Explaining State Differences in Applying for a Recent Long-Term Care Program that Promotes Aging in Place: Perspectives of Medicaid Administrators.

Older adults in need of assistance often prefer to remain at home rather than receive care in an institution. To meet these preferences, Medicaid invited states to apply for the Balancing Incentive Program (BIP), a program intended to "rebalance" Medicaid-financed long-term services and supports to Home- and Community-Based Services (HCBS). However, only about half of eligible states applied. We interviewed Medicaid administrators to explore why some states applied for BIP whereas others did not. Supportive state leadership and the presence of other programs supporting community-based care were positively related to BIP application. Opposing policy priorities and programs competing for similar resources were negatively related to BIP application. Because states most likely to apply already had policy goals and programs supporting HCBS, BIP may inadvertently widen disparities across states, pushing those on the margins ahead and leaving the ones that are worst off in HCBS support to fall even further behind.

Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports: Stakeholder Perspectives From 14 States.

OBJECTIVES: Trends over time in the United States show success in rebalancing long-term services and supports (LTSS) toward increased home- and community-based services (HCBS) relative to institutionalized care. However, the diffusion and utilization of HCBS may be inequitable across rural and urban residents. We sought to identify potential disparities in rural HCBS access and utilization, and to elucidate factors associated with these disparities. DESIGN: We used qualitative interviews with key informants to explore and identify potential disparities and their associated supply-side factors. SETTING AND PARTICIPANTS: We interviewed 3 groups of health care stakeholders (Medicaid administrators, service agency managers and staff, and patient advocates) from 14 states (n = 40). MEASURES: Interviews were conducted using a semistructured interview guide, and data were thematically coded using a standardized codebook. RESULTS: Stakeholders identified supply-side factors inhibiting rural HCBS access, including limited availability of LTSS providers, inadequate transportation services, telecommunications barriers, threats to business viability, and challenges to caregiving workforce recruitment and retention. Stakeholders perceived that rural persons have a greater reliance on informal caregiving supports, either as a cultural preference or as compensation for the dearth of HCBS. CONCLUSIONS/IMPLICATIONS: LTSS rebalancing efforts that limit the institutional LTSS safety net may have unintended consequences in rural contexts if they do not account for supply-side barriers to HCBS. We identified supply-side factors that (1) inhibit beneficiaries' access to HCBS, (2) affect the adequacy and continuity of HCBS, and (3) potentially impact long-term business viability for HCBS providers. Spatial isolation of beneficiaries may contribute to a perceived lack of demand and reduce chances of funding for new services. Addressing these problems requires stakeholder collaboration and comprehensive policy approaches with attention to rural infrastructure.

Secular Trends in Dementia and Cognitive Impairment of U.S. Rural and Urban Older Adults.

INTRODUCTION: This is a nationally representative study of rural-urban disparities in the prevalence of probable dementia and cognitive impairment without dementia (CIND). METHODS: Data on non-institutionalized U.S. adults from the 2000 (n=16,386) and 2010 (n=16,311) cross-sections of the Health and Retirement Study were linked to respective Census assessments of the urban composition of residential census tracts. Relative risk ratios (RRR) for rural-urban differentials in dementia and CIND respective to normal cognitive status were assessed using multinomial logistic regression. Analyses were conducted in 2016. RESULTS: Unadjusted prevalence of dementia and CIND in rural and urban tracts converged so that rural disadvantages in the relative risk of dementia (RRR=1.42, 95% CI=1.10, 1.83) and CIND (RRR=1.35, 95% CI=1.13, 1.61) in 2000 no longer reached statistical significance in 2010. Adjustment for the strong protective role of educational attainment reduced rural disadvantages in 2000 to statistical nonsignificance, whereas adjustment for race/ethnicity resulted in a statistically significant increase in RRRs in 2010. Full adjustment for sociodemographic and health factors revealed persisting rural disadvantages for dementia and CIND in both periods with RRR in 2010 for dementia of 1.79 (95% CI=1.31, 2.43) and for CIND of 1.38 (95% CI=1.14, 1.68). CONCLUSIONS: Larger gains in rural adults' cognitive functioning between 2000 and 2010 that are linked with increased educational attainment demonstrate long-term public health benefits of investment in secondary education. Persistent disadvantages in cognitive functioning among rural adults compared with sociodemographically similar urban peers highlight the importance of public health planning for more rapidly aging rural communities.

Examination of neighborhood disadvantage and sleep in a multi-ethnic cohort of adolescents.

PURPOSE: Neighborhood-level socioeconomic disadvantage and lower individual-level socioeconomic status are associated with poorer sleep health in adults. However, few studies have examined the association between neighborhood-level disadvantage and sleep in adolescents, a population at high-risk for sleep disturbances. METHODS: The current study is the first to examine how objective (i.e. via census tract-level data) and subjective measures of neighborhood disadvantage are associated with sleep in a racially/ ethnically and socioeconomically diverse sample of 2493 youth [Non-Hispanic White (20%), Hispanic (46%), Asian (21%), and Multiracial/ Other (13%)]. RESULTS: Findings indicated that greater perceived neighborhood-level social cohesion and lower neighborhood-level poverty were associated with better sleep outcomes in adolescents. However, there was some evidence that the magnitude of the associations differed according to family-level socioeconomic status and race/ ethnicity. CONCLUSIONS: Findings suggest that subjective and objective neighborhood characteristics may affect the sleep health of older adolescents, with certain demographic subgroups being particularly vulnerable.

Opioid analgesic and benzodiazepine prescribing among Medicaid-enrollees with opioid use disorders: The influence of provider communities.

Opioid analgesic and benzodiazepine use in individuals with opioid use disorders can increase the risk for medical consequences and relapse. Little is known about rates of use of these medications or prescribing patterns among communities of prescribers. The goal of this study was to examine rates of prescribing to Medicaid-enrollees in the calendar year after an opioid use disorder diagnosis, and to examine individual, county, and provider community factors associated with such prescribing. 2008 Medicaid claims data were used from 12 states to identify enrollees diagnosed with opioid use disorders, and 2009 claims data were used to identify rates of prescribing of each drug. Social network analysis was used to identify provider communities, and multivariate regression analyses was used to to identify patient, county, and provider community level factors associated with prescribing these drugs. The authors also examined variation in rates of prescribing across provider communities. Among Medicaid-enrollees identified with an opioid use disorder, 45% filled a prescription for an opioid analgesic, 37% filled a prescription for a benzodiazepine, and 21% filled a prescription for both in the year following their diagnosis. Females, older individuals, individuals with pain syndromes, and individuals residing in counties with higher rates of poverty were more likely to fill prescriptions. Prescribing rates varied substantially across provider communities, with rates in the highest quartile of prescribing communities over 2.5 times the rates in the lowest prescribing communities. Prescribing opioid analgesics and benzodiazepines to individuals diagnosed with opioid use disorders may increase risk of relapse and overdose. Interventions should be considered that target provider communities with the highest rates of prescribing and individuals at the highest risk.

Neighborhood age structure and cognitive function in a nationally-representative sample of older adults in the U.S.

Recent evidence suggests that living in a neighborhood with a greater percentage of older adults is associated with better individual health, including lower depression, better self-rated health, and a decreased risk of overall mortality. However, much of the work to date suffers from four limitations. First, none of the U.S.-based studies examine the association at the national level. Second, no studies have examined three important hypothesized mechanisms - neighborhood socioeconomic status and neighborhood social and physical characteristics - which are significantly correlated with both neighborhood age structure and health. Third, no U.S. study has longitudinally examined cognitive health trajectories. We build on this literature by examining nine years of nationally-representative data from the Health and Retirement Study (2002-2010) on men and women aged 51 and over linked with Census data to examine the relationship between the percentage of adults 65 and older in a neighborhood and individual cognitive health trajectories. Our results indicate that living in a neighborhood with a greater percentage of older adults is related to better individual cognition at baseline but we did not find any significant association with cognitive decline. We also explored potential mediators including neighborhood socioeconomic status, perceived neighborhood cohesion and perceived neighborhood physical disorder. We did not find evidence that neighborhood socioeconomic status explains this relationship; however, there is suggestive evidence that perceived cohesion and disorder may explain some of the association between age structure and cognition. Although more work is needed to identify the precise mechanisms, this work may suggest a potential contextual target for public health interventions to prevent cognitive impairment.

Lagged Associations of Metropolitan Statistical Area- and State-Level Income Inequality with Cognitive Function: The Health and Retirement Study.

PURPOSE: Much variation in individual-level cognitive function in late life remains unexplained, with little exploration of area-level/contextual factors to date. Income inequality is a contextual factor that may plausibly influence cognitive function. METHODS: In a nationally-representative cohort of older Americans from the Health and Retirement Study, we examined state- and metropolitan statistical area (MSA)-level income inequality as predictors of individual-level cognitive function measured by the 27-point Telephone Interview for Cognitive Status (TICS-m) scale. We modeled latency periods of 8-20 years, and controlled for state-/metropolitan statistical area (MSA)-level and individual-level factors. RESULTS: Higher MSA-level income inequality predicted lower cognitive function 16-18 years later. Using a 16-year lag, living in a MSA in the highest income inequality quartile predicted a 0.9-point lower TICS-m score (ß = -0.86; 95% CI = -1.41, -0.31), roughly equivalent to the magnitude associated with five years of aging. We observed no associations for state-level income inequality. The findings were robust to sensitivity analyses using propensity score methods. CONCLUSIONS: Among older Americans, MSA-level income inequality appears to influence cognitive function nearly two decades later. Policies reducing income inequality levels within cities may help address the growing burden of declining cognitive function among older populations within the United States.

Individual and Neighborhood Socioeconomic Status and the Association between Air Pollution and Cardiovascular Disease.

BACKGROUND: Long-term fine particulate matter (PM2.5) exposure is linked with cardiovascular disease, and disadvantaged status may increase susceptibility to air pollution-related health effects. In addition, there are concerns that this association may be partially explained by confounding by socioeconomic status (SES). OBJECTIVES: We examined the roles that individual- and neighborhood-level SES (NSES) play in the association between PM2.5 exposure and cardiovascular disease. METHODS: The study population comprised 51,754 postmenopausal women from the Women's Health Initiative Observational Study. PM2.5 concentrations were predicted at participant residences using fine-scale regionalized universal kriging models. We assessed individual-level SES and NSES (Census-tract level) across several SES domains including education, occupation, and income/wealth, as well as through an NSES score, which captures several important dimensions of SES. Cox proportional-hazards regression adjusted for SES factors and other covariates to determine the risk of a first cardiovascular event. RESULTS: A 5 µg/m3 higher exposure to PM2.5 was associated with a 13% increased risk of cardiovascular event [hazard ratio (HR) 1.13; 95% confidence interval (CI): 1.02, 1.26]. Adjustment for SES factors did not meaningfully affect the risk estimate. Higher risk estimates were observed among participants living in low-SES neighborhoods. The most and least disadvantaged quartiles of the NSES score had HRs of 1.39 (95% CI: 1.21, 1.61) and 0.90 (95% CI: 0.72, 1.07), respectively. CONCLUSIONS: Women with lower NSES may be more susceptible to air pollution-related health effects. The association between air pollution and cardiovascular disease was not explained by confounding from individual-level SES or NSES. Citation: Chi GC, Hajat A, Bird CE, Cullen MR, Griffin BA, Miller KA, Shih RA, Stefanick ML, Vedal S, Whitsel EA, Kaufman JD. 2016. Individual and neighborhood socioeconomic status and the association between air pollution and cardiovascular disease. Environ Health Perspect 124:1840-1847; http://dx.doi.org/10.1289/EHP199.

Constructing a Time-Invariant Measure of the Socio-economic Status of U.S. Census Tracts.

Contextual research on time and place requires a consistent measurement instrument for neighborhood conditions in order to make unbiased inferences about neighborhood change. We develop such a time-invariant measure of neighborhood socio-economic status (NSES) using exploratory and confirmatory factor analyses fit to census data at the tract level from the 1990 and 2000 U.S. Censuses and the 2008-2012 American Community Survey. A single factor model fit the data well at all three time periods, and factor loadings--but not indicator intercepts--could be constrained to equality over time without decrement to fit. After addressing remaining longitudinal measurement bias, we found that NSES increased from 1990 to 2000, and then--consistent with the timing of the "Great Recession"--declined in 2008-2012 to a level approaching that of 1990. Our approach for evaluating and adjusting for time-invariance is not only instructive for studies of NSES but also more generally for longitudinal studies in which the variable of interest is a latent construct.

Neighbourhood racial/ethnic composition and segregation and trajectories of cognitive decline among US older adults.

BACKGROUND: The influence of the sociodemographic context of one's environment on cognitive ageing is not well understood. METHODS: We examined differences in cognitive trajectories according to the racial/ethnic characteristics of the residential environment. On the basis of 63 996 person-years of data from a nationally representative cohort of 6150 adults over the age of 50 years from the Health and Retirement Study, we used multivariate linear mixed models to determine the effect of neighbourhood racial/ethnic composition and county-level segregation on cognitive function and cognitive decline over a 10-year period. RESULTS: In models adjusting for individual demographic and health characteristics, Hispanic composition had a significant positive association with cognitive function (standardised ß=0.136, p<0.05) and moderate evidence of an association with greater cognitive decline (standardised ß=-0.014, p=0.09). Greater Hispanic-white segregation was associated with statistically significant higher cognitive function at baseline (standardised ß=0.099, p<0.001) and greater cognitive decline (standardised ß=-0.011, p<0.01). For a 20 percentage-point increase in Hispanic composition and segregation, the observed associations implied 1 and 1.25 additional years of cognitive ageing over 10 years, respectively. These effects did not differ by individual race/ethnicity and were not explained by neighbourhood socioeconomic status or neighbourhood selection. Black composition and black-white segregation did not have a significant influence on cognitive ageing. DISCUSSION: This study demonstrates disparities in the progression of cognitive ageing according to racial/ethnic characteristics of the neighbourhood environment.