Reported Unmet Hearing Aid Need in Older People With Dementia: The US National Core Indicators Survey.

OBJECTIVES: Hearing aids have important health benefits for older adults with Alzheimer disease and related dementias (ADRD); however, hearing aid adoption in this group is low. This study aimed to determine where to target hearing aid interventions for American long-term care recipients with ADRD by examining the association of ADRD and residence type with respondent-reported unmet hearing aid need. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the United States National Core Indicators-Aging and Disabilities survey (2015-2019) for long-term care recipients aged ≥65 years. METHODS: We used multivariable logistic regression to model the likelihood of reporting unmet hearing aid need conditional on ADRD status and residence type (own/family house or apartment, residential care, or nursing facility/home), adjusting for sociodemographic factors and response type (self vs proxy). RESULTS: Of the 25,492 respondents [median (IQR) age, 77 (71, 84) years; 7074 (27.8%) male], 5442 (21.4%) had ADRD and 3659 (14.4%) owned hearing aids. Residence types were 17,004 (66.8%) own/family house or apartment, 4966 (19.5%) residential care, and 3522 (13.8%) nursing home. Among non-hearing aid owners, ADRD [adjusted odds ratio (AOR) 0.90, 95% CI 0.80-1.0] and residence type were associated with respondent-reported unmet hearing aid need. Compared to the nursing home reference group, respondents in their own/family home (AOR 1.85, 95% CI 1.61-2.13) and residential care (AOR 1.30, 95% CI 1.10-1.53) were more likely to report unmet hearing aid need. This pattern was significantly more pronounced in people with ADRD than in those without, stemming from an interaction between ADRD and residence type. CONCLUSIONS AND IMPLICATIONS: American long-term care recipients with ADRD living in their own/family home are more likely to report unmet hearing aid need than those with ADRD in institutional and congregate settings. This information can inform the design and delivery of hearing interventions for older adults with ADRD.

Examining Satisfaction and Quality in Home- and Community-Based Service Programs in the United States: A Scoping Review.

BACKGROUND AND OBJECTIVES: Long-term services and supports in the United States are increasingly reliant on home- and community-based services (HCBS). Yet, little is known about the quality of HCBS. We conducted a scoping review of the peer-reviewed literature to summarize HCBS consumer, provider, and stakeholder satisfaction with services as a means of assessing quality. RESEARCH DESIGN AND METHODS: We searched PubMed, OVID-MEDLINE, and SCOPUS to identify articles published from 2000 to 2021 that reported on studies describing a U.S.-based study population. Articles were grouped into 3 categories: drivers of positive consumer satisfaction, drivers of negative consumer satisfaction, and provider and stakeholder perspectives on satisfaction. RESULTS: Our final sample included 27 articles. Positive perceptions of quality and reported satisfaction with services were driven by consistent, reliable, and respectful care providers, and adoption of person-centered models of service delivery. Mistreatment of consumers, staff turnover, training, service interruptions, and unmet functional needs were drivers of negative consumer perceptions of quality. Support for caregivers and emphasis on training were identified by providers and stakeholders as important for providing satisfactory services. DISCUSSION AND IMPLICATIONS: Multiple data challenges limit the ability to systematically evaluate HCBS program quality; however, studies examining single programs found that HCBS consumers are more satisfied and associate higher quality with easy-to-navigate programs and professional staff. Efforts to expand HCBS should also include requirements to systematically evaluate quality outcomes.

Age Differences in Determinants of Self-Rated Health among Recipients of Publicly Funded Home-and-Community-Based Services.

This research examined determinants of self-rated health (SRH) of publicly funded home-and-community-based services (HCBS) recipients and tested if the effects of determinants differ between older recipients and younger recipients with disabilities. Using Minnesota's data of 2015-2016 National Core Indicators - Aging and Disabilities survey (n = 3,426), this study revealed that functional status and community inclusion had both direct and indirect effects on SRH, with negative mood as a mediator. Community inclusion had a more pronounced effect on SRH in younger recipients than in older recipients. HCBS should address psychosocial needs and be tailored for recipients of different age groups.

Simultaneously Developing Interventions for Low-/Middle-Income and High-Income Settings: Considerations and Opportunities.

Most older adults reside in low- and middle-income countries (LMICs) but most research dollars spent on interventions to improve the lives of older adults are awarded to researchers in high-income countries (HICs). One approach to improve the implementation of evidence-based innovations for older adults in LMICs is designing interventions that are relevant to LMICs and HICs simultaneously. We propose that researchers in HICs could partner with stakeholders in an LMIC throughout the intervention design process to better position their intervention for the implementation in that LMIC. We provide an example study from an adaptation of the Resources for Enhancing Caregiver Health II in Vietnam, which did not use this strategy but may have benefited from this strategy. We then turn to several considerations that are important for researchers to contemplate when incorporating this strategy. Finally, we explore incentives for creating interventions that are relevant to both HICs and LMICs for funders, intervention designers, and intervention receivers. Although this is not the only strategy to bring interventions to LMICs, it may represent another tool in researchers' toolboxes to help expedite the implementation of efficacious interventions in LMICs.

Identifying Nursing Homes With Diverse Racial and Ethnic Resident Compositions: The Importance of Group Heterogeneity and Geographic Context.

Racial/ethnic composition of nursing home (NH) plays a particularly important role in NH quality. A key methodological issue is defining when an NH serves a low versus high proportion of racially/ethnically diverse residents. Using the Minimum Data Set from 2015 merged with Certification and Survey Provider Enhanced Reports, we calculated the racial/ethnic composition of U.S.-based NHs for Black or Hispanic residents specifically, and a general Black, Indigenous, and People of Color (BIPOC) grouping for long-stay residents. We examined different definitions of having a high racial/ethnic composition by varying percentile thresholds of composition, state-specific and national thresholds, and restricting composition to BIPOC residents as well as only Black and Hispanic residents. NHs with a high racial/ethnic composition have different facility characteristics than the average NH. Based on this, we make suggestions for how to identify NHs with diverse racial/ethnic resident compositions.

Evidence to Inform Policy and Practice: Mechanisms to Address Racial/Ethnic Disparities in Nursing Home Quality of Life.

Background and Objectives: Abundant evidence documents racial/ethnic disparities in access, quality of care, and quality of life (QoL) among nursing home (NH) residents who are Black, Indigenous, and people of color (BIPOC) compared with White residents. BIPOC residents are more likely to be admitted to lower quality NHs and to experience worse outcomes. Yet, little is known about processes for differences in QoL among residents receiving care in high-proportion BIPOC NHs. This study presents an examination of the processes for racial/ethnic disparities in QoL in high-proportion BIPOC facilities while highlighting variability in QoL between these facilities. Research Design and Methods: Guided by the Minority Health and Health Disparities Research Framework and the Zubritsky framework for QoL in NHs, we employ a concurrent mixed-methods approach involving in-depth case studies of 6 high-proportion BIPOC NHs in Minnesota (96 resident interviews; 61 staff interviews; 614 hours of observation), coupled with statewide survey data on residents' QoL linked to resident clinical Minimum Data Set assessments. Results: Quantitative findings show that BIPOC residents experience lower QoL than White residents across various domains. Qualitative findings reveal variability in BIPOC residents' QoL between high-proportion BIPOC facilities. In some facilities, BIPOC residents experienced worse QoL based on their race/ethnicity, whereas in others BIPOC residents QoL was not directly affected by their race/ethnicity or they had mixed experiences. Discussion and Implications: The findings highlight variability in racial/ethnic disparities in QoL across NHs with a high proportion of BIPOC residents. We identify health equity initiatives, including engaging with community BIPOC organizations and volunteers, and providing more resources to high-proportion BIPOC facilities to support staff training, additional staffing, and culturally specific programming. Given the increasing racial/ethnic diversity of NHs, ensuring equity in QoL for BIPOC residents is an urgent priority for NHs to remain relevant in the future.

Decomposing Racial and Ethnic Disparities in Nursing Home Quality of Life.

This study examines the racial/ethnic disparity among nursing home (NH) residents using a self-reported, validated measure of quality of life (QoL) among long-stay residents in Minnesota. Blinder-Oaxaca decomposition techniques determine which resident and facility factors are the potential sources of the racial/ethnic disparities in QoL. Black, Indigenous, and other People of Color (BIPOC) report lower QoL than White residents. Facility structural characteristics and being a NH with a high proportion of residents who are BIPOC are the factors that have the largest explanatory share of the disparity. Modifiable characteristics like staffing levels explain a small share of the disparity. To improve the QoL of BIPOC NH residents, efforts need to focus on addressing systemic disparities for NHs with a high proportion of residents who are BIPOC.

Racial/Ethnic Disparities in Self-Rated Health and Sense of Control for Older Adults Receiving Publicly Funded Home- and Community-Based Services.

Objectives: This study examines racial/ethnic differences in self-rated health (SRH) and sense of control among older adults receiving publicly funded home- and community-based services (HCBS) and tests the mediating role of functional, emotional, and financial stressors. Methods: Data are from 2015 National Core Indicators-Aging and Disability Survey collected from face-to-face interviews with 1936 older adults aged 65 years or older receiving HCBS in Minnesota. Path analysis based on logistic regression was used. Results: Racial/ethnic minority HCBS users had lower SRH and sense of control than white participants, with Asian participants reporting the lowest scores. Whereas functional impairment was a common explanatory factor for the racial/ethnic differences, negative mood and financial strain were mediators for Asian and Hispanic/Latino participants, respectively. Discussion: Racial/ethnic disparities in well-being exist among older HCBS users, with different mediators at play. Customized services are needed to meet diverse needs of older adults of different racial/ethnic groups.

Does Living in a Higher Proportion Minority Facility Improve Quality of Life for Racial/Ethnic Minority Residents in Nursing Homes?

BACKGROUND AND OBJECTIVES: The proportion of racial/ethnic minority older adults in nursing homes (NHs) has increased dramatically and will surpass the proportion of white adults by 2030.Yet, little is known about minority groups' experiences related to the quality of life (QOL). QOL is a person-centered measure, capturing multiple aspects of well-being. NH quality has been commonly measured using clinical care indicators, but there is growing recognition for the need to include QOL. This study examines the role of individual race/ethnicity, facility racial/ethnic composition, and the interaction of both for NH resident QOL. RESEARCH DESIGN AND METHODS: We used a unique state-level data set that includes self-reported QOL surveys with a random sample of long-stay Minnesota NH residents, using a multidimensional measure of QOL. These surveys were linked to resident clinical data from the Minimum Dataset 3.0 and facility-level characteristics. Minnesota is one of the two states in the nation that collects validated QOL measures, linked to data on resident and detailed facility characteristics. We used mixed-effects models, with random intercepts to model summary QOL score and individual domains. RESULTS: We identified significant racial disparities in NH resident QOL. Minority residents report significantly lower QOL scores than white residents, and NHs with higher proportion minority residents have significantly lower QOL scores. Minority residents have significantly lower adjusted QOL than white residents, whether they are in low- or high-minority facilities, indicating a remaining gap in individual care needs. DISCUSSION AND IMPLICATIONS: The findings highlight system-level racial disparities in NH residents QOL, with residents who live in high-proportion minority NHs facing the greatest threats to their QOL. Efforts need to focus on reducing racial/ethnic disparities in QOL, including potential public reporting (similar to quality of care) and resources and attention to provision of culturally sensitive care in NHs to address residents' unique needs.

COVID-19 Pandemic: Exacerbating Racial/Ethnic Disparities in Long-Term Services and Supports.

What services are available and where racial and ethnic minorities receive long-term services and supports (LTSS) have resulted in a lower quality of care and life for racial/ethnic minority users. These disparities are only likely to worsen during the COVID-19 pandemic, as the pandemic has disproportionately affected racial and ethnic minority communities both in the rate of infection and virus-related mortality. By examining these disparities in the context of the pandemic, we bring to light the challenges and issues faced in LTSS by minority communities with regard to this virus as well as the disparities in LTSS that have always existed.

Long-Term Effects of Age Discrimination on Mental Health: The Role of Perceived Financial Strain.

OBJECTIVES: This study examines the role of work-related perceived age discrimination on women's mental health over the life course and tests whether financial strain mediates this relationship. METHODS: Using the National Longitudinal Survey of Mature Women (1967-2003), we employ nested growth curve models to evaluate whether perceived age discrimination at work influences women's depressive symptoms and life satisfaction and whether perceived financial strain mediates this relationship. RESULTS: Women who experienced age discrimination had greater overall depressive symptoms but not after controlling for financial strain. We found evidence that age discrimination affected financial strain, which, in turn, increased women's depressive symptoms. Women who reported age discrimination had lower odds of being in higher categories of overall life satisfaction; financial strain partially mediated the relationship but age discrimination remained a significant predictor. DISCUSSION: Despite legal protection, age discrimination at work is frequent and has significant effects on women's mental health over the life course. Financial strain partially mediates this relationship, pointing to financial implications of perceived age discrimination for women and their families. Our findings have important policy and workplace implications, calling attention to ageism as a potent stressor for working women's mental health beyond those tied to sex or race.

Quasi-Experimental Evaluation of LifeCourse on Utilization and Patient and Caregiver Quality of Life and Experience.

Whole-person care is a new paradigm for serious illness, but few programs have been robustly studied. We sought to test the effect of LifeCourse (LC), a person-centered program for patients living with serious illness, on health-care utilization, care experience, and quality of life, employing a quasi-experimental design with a Usual Care (UC) comparison group. The study was conducted 2012 to 2017 at an upper-Midwest not-for-profit health-care system with outcomes measured every 3 months until the end of life. Enrolled patients (N = 903) were estimated to be within 3 years of end of life and diagnosed with 1+ serious illness. Exclusion criteria included hospice enrollment at time of screening or active dying. Community health workers (CHWs) delivered standardized monthly 1-hour home visits based on palliative care guidelines and motivational interviewing to promote patients' physical, psychosocial, and financial well-being. Primary outcomes included health-care utilization and patient- and caregiver-experience and quality of life. Patients were elderly (LC 74, UC 78 years) and primarily non-Hispanic, white, living at home with cardiovascular disease as the primary diagnosis (LC 69%, UC 57%). A higher proportion of LC patients completed advance directives (N = 173, 38%) than UC patients (N = 66, 15%; P < .001). LifeCourse patients who died spent more days in hospice (88 ± 191 days) compared to UC patients (44 ± 71 days; P = .018). LifeCourse patients reported greater improvements than UC in communication as part of the care experience ( P = .016). Implementation of person-centered programs delivered by CHWs is feasible; inexpensive upstream expansion of palliative care models can yield benefits for patients and caregivers. Trial Registration: Trial NCT01746446 was registered on November 27, 2012 at ClinicalTrials.gov .

Does the Volume of Post-Acute Care Affect Quality of Life in Nursing Homes?

Although short-stay, post-acute nursing home stays are increasing, little is known about the impact of volume of post-acute care on quality of life (QOL) within nursing homes. We analyzed data from the 2010 Minnesota QOL and Consumer Satisfaction survey ( N = 13,433 residents within 377 facilities) and federal Minimum Data Set to determine the influence of living in a facility with an above-average proportion of post-acute care residents on six domains of resident QOL. In bivariate analyses, an above-average proportion of Medicare-funded post-acute care had a significant negative influence on four domains (mood, environment, food, engagement) and overall facility QOL. However, when resident and facility covariates were added to the model, only the food domain remained significant. Although the challenges of caring for residents with a diverse set of treatment and caregiving goals may negatively affect overall facility QOL, negative impacts are moderated by individual resident and nursing home characteristics.

Place of Death of Individuals with Terminal Cancer: New Insights from Medicare Hospice Place-of-Service Codes.

OBJECTIVES: To use place-of-service (POS) codes in the Medicare hospice claims files to document where elderly hospice users with cancer die. DESIGN: Retrospective cohort study. SETTING: Surveillance, Epidemiology, and End Results (SEER) cancer registry areas. PARTICIPANTS: Elderly Medicare beneficiaries who died of lung, breast, colorectal, or pancreatic cancer in 2007 and 2008 (N = 46,037). MEASUREMENT: Use of hospice, place of service at death (home, nursing home, hospital, inpatient hospice, other), length of stay in hospice. RESULTS: Two-thirds of the beneficiaries used hospice. Younger, male, black, Asian, and unmarried beneficiaries and those enrolled in fee-for-service Medicare or from areas with lower income were less likely to use hospice. Hospice enrollment also varied significantly according to SEER registry. Thirty percent of the hospice users were not receiving home-based care at the time of death, and 17% were enrolled for less than 3 days. Factors associated with hospice death in the home mirrored those associated with hospice use. Individuals dying in hospitals (odds ratio (OR) = 5.13, 95% confidence interval (CI) = 4.63-5.69), inpatient hospice (OR = 1.86, 95% CI = 1.70-2.02), and nursing homes (OR = 1.19, 95% CI = 1.10-1.28) had greater odds of a short hospice stay (≤7 days) than those dying at home, after controlling for all other measured factors, whereas those dying in nursing homes had greater odds of long stays (>180 days) (OR = 1.46, 95% CI = 1.28-1.67). CONCLUSION: New hospice POS codes are useful for understanding place of death for hospice users. Hospice deaths cannot be assumed to happen at home.

Racial Differences in Minnesota Nursing Home Residents' Quality of Life: The Importance of Looking Beyond Individual Predictors.

OBJECTIVES: The aim of this study is to investigate racial differences in nursing home (NH) residents' quality of life (QOL) at the resident and facility levels. METHOD: We used hierarchical linear modeling to identify significant resident- and facility-level predictors for racial differences in six resident-reported QOL domains. Data came from the following: (a) resident-reported QOL (n = 10,929), (b) the Minimum Data Set, and (c) facility-level characteristics from the Minnesota Department of Human Services (n = 376). RESULTS: White residents reported higher QOL in five of six domains, but in full models, individual-level racial differences remained only for food enjoyment. On the facility level, higher percentage of White residents was associated with better scores in three domains, even after adjusting for all characteristics. DISCUSSION: Racial differences in QOL exist on individual and aggregate levels. Individual differences are mainly explained by health status. The finding that facility racial composition predicts QOL more than individual race underscores the importance of examining NH structural characteristics and practices.

Examining the Impact of Maternal Health, Race, and Socioeconomic Status on Daughter's Self-Rated Health Over Three Decades.

This study examines the role of mother's health and socioeconomic status on daughter's self-rated health using data spanning three decades from the National Longitudinal Surveys of Mature Women and Young Women (N = 1,848 matched mother-daughter pairs; 1,201 White and 647 African American). Using nested growth curve models, we investigated whether mother's self-rated health affected the daughter's self-rated health and whether socioeconomic status mediated this relationship. Mother's health significantly influenced daughters' self-rated health, but the findings were mediated by mother's socioeconomic status. African American daughters reported lower self-rated health and experienced more decline over time compared with White daughters, accounting for mother's and daughter's covariates. Our findings reveal maternal health and resources as a significant predictor of daughters' self-rated health and confirm the role of socioeconomic status and racial disparities over time.

Differences by Sexual Orientation in Expectations About Future Long-Term Care Needs Among Adults 40 to 65 Years Old.

OBJECTIVES: We examined whether and how lesbian, gay, and bisexual (LGB) adults between 40 and 65 years of age differ from heterosexual adults in long-term care (LTC) expectations. METHODS: Our data were derived from the 2013 National Health Interview Survey. We used ordered logistic regression to compare the odds of expected future use of LTC among LGB (n = 297) and heterosexual (n = 13 120) adults. We also used logistic regression models to assess the odds of expecting to use specific sources of care. All models controlled for key socioeconomic characteristics. RESULTS: Although LGB adults had greater expectations of needing LTC in the future than their heterosexual counterparts, that association was largely explained by sociodemographic and health differences. After control for these differentials, LGB adults were less likely to expect care from family and more likely to expect to use institutional care in old age. CONCLUSIONS: LGB adults may rely more heavily than heterosexual adults on formal systems of care. As the older population continues to diversify, nursing homes and assisted living facilities should work to ensure safety and culturally sensitive best practices for older LGB groups.

Expectations about future use of long-term services and supports vary by current living arrangement.

Most Americans know little about options for long-term services and supports and underestimate their likely future needs for such assistance. Using data from the 2012 National Health Interview Survey, we examined expectations about future use of long-term services and supports among adults ages 40-65 and how these expectations varied by current living arrangement. We found differences by living arrangement in expectations about both future need for long-term services and supports and who would provide such care if needed. Respondents living with minor children were the least likely to expect to need long-term services and supports and to require paid care if the need arose. In contrast, respondents living alone were the most likely to expect that it was "very likely" that they would need long-term services and supports and to rely on paid care. Overall, we found a disconnect between expectations of use and likely future reality: 60 percent of respondents believed that they were unlikely to need long-term services and supports in the future, whereas the evidence suggests that nearly 70 percent of older adults will need them at some point. These findings both underscore the need for programs that encourage people to plan for long-term services and supports and indicate that information about living arrangements can be useful in developing and targeting such programs.

Health insurance coverage and racial disparities in breast reconstruction after mastectomy.

BACKGROUND: Breast reconstruction after mastectomy offers clinical, cosmetic, and psychological benefits compared with mastectomy alone. Although reconstruction rates have increased, racial/ethnic disparities in breast reconstruction persist. Insurance coverage facilitates access to care, but few studies have examined whether health insurance ameliorates disparities. METHODS: We used the Nationwide Inpatient Sample for 2002 through 2006 to examine the relationships between health insurance coverage, race/ethnicity, and breast reconstruction rates among women who underwent mastectomy for breast cancer. We examined reconstruction rates as a function of the interaction of race and the primary payer (self-pay, private health insurance, government) while controlling for patient comorbidity, and we used generalized estimating equations to account for clustering and hospital characteristics. FINDINGS: Minority women had lower breast reconstruction rates than White women (adjusted odds ratio [AOR], 0.57 for African American; AOR, 0.70 for Hispanic; AOR, 0.45 for Asian; p < .001). Uninsured women (AOR, 0.33) and those with public coverage were less likely to undergo reconstruction (AOR, 0.35; p < .001) than privately insured women. Racial/ethnic disparities were less prominent within insurance types. Minority women, whether privately or publicly insured, had lower odds of undergoing reconstruction than White women. Among those without insurance, reconstruction rates did not differ by race/ethnicity. CONCLUSIONS: Insurance facilitates access to care, but does not eliminate racial/ethnic disparities in reconstruction rates. Our findings-which reveal persistent health care disparities not explained by patient health status-should prompt efforts to promote both access to and use of beneficial covered services for women with breast cancer.

An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs: financial and non-financial barriers have different associations.

BACKGROUND: Emergency department (ED) use is costly, and especially frequent among publicly insured populations in the US, who also disproportionately encounter financial (cost/coverage-related) and non-financial/practical barriers to care. The present study examines the distinct associations financial and non-financial barriers to care have with patterns of ED use among a publicly insured population. METHODS: This observational study uses linked administrative-survey data for enrollees of Minnesota Health Care Programs to examine patterns in ED use-specifically, enrollee self-report of the ED as usual source of care, and past-year count of 0, 1, or 2+ ED visits from administrative data. Main independent variables included a count of seven enrollee-reported financial concerns about healthcare costs and coverage, and a count of seven enrollee-reported non-financial, practical barriers to access (e.g., limited office hours, problems with childcare). Covariates included health, health care, and demographic measures. RESULTS: In multivariate regression models, only financial concerns were positively associated with reporting ED as usual source of care, but only non-financial barriers were significantly associated with greater ED visits. Regression-adjusted values indicated notable differences in ED visits by number of non-financial barriers: zero non-financial barriers meant an adjusted 78% chance of having zero ED visits (95% C.I.: 70.5%-85.5%), 15.9% chance of 1(95% C.I.: 10.4%-21.3%), and 6.2% chance (95% C.I.: 3.5%-8.8%) of 2+ visits, whereas having all seven non-financial barriers meant a 48.2% adjusted chance of zero visits (95% C.I.: 30.9%-65.6%), 31.8% chance of 1 visit (95% C.I.: 24.2%-39.5%), and 20% chance (95% C.I.: 8.4%-31.6%) of 2+ visits. CONCLUSIONS: Financial barriers were associated with identifying the ED as one's usual source of care but non-financial barriers were associated with actual ED visits. Outreach/literacy efforts may help reduce reliance on/perception of ED as usual source of care, whereas improved targeting/availability of covered services may help curb frequent actual visits, among publicly insured individuals.