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1.
JAMA Health Forum ; 4(12): e234240, 2023 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-38064239

RESUMO

Importance: Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population. Objective: To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. Design, Setting, and Participants: This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020. Exposure: Race and ethnicity. Main Outcomes and Measures: Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death. Results: Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85). Conclusions and Relevance: Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.


Assuntos
Cuidados Paliativos na Terminalidade da Vida , Hospitais para Doentes Terminais , Idoso , Humanos , Masculino , Feminino , Estados Unidos/epidemiologia , Medicaid , Medicare , Estudos Retrospectivos , Estudos de Coortes , Qualidade de Vida
2.
J Am Med Dir Assoc ; 24(12): 1918-1923, 2023 12.
Artigo em Inglês | MEDLINE | ID: mdl-37918816

RESUMO

Medicaid-funded home and community-based services (HCBSs) reach large numbers of individuals living with dementia who would otherwise reside in nursing homes with Medicaid funding. Medicaid HCBSs also often augment care provided by family and other informal caregivers to individuals living with dementia. Although Medicaid-funded HCBSs are offered in most states in lieu of nursing home care, they have been largely overlooked as health care system partners for implementation and testing of evidence-based dementia care interventions using embedded pragmatic clinical trial (ePCT) designs. In this article, we make the case for the importance of Medicaid-funded HCBSs as dementia care ePCT partners because of the volume of vulnerable clients with dementia served and the potential positive impacts that evidence-based dementia care programs can have on clients and their informal caregivers. This article first characterizes the Medicaid HCBS setting in terms of populations served and organizational arrangements across states. We then characterize strengths and potential limitations presented by Medicaid HCBSs as settings within which to implement dementia care ePCTs, using as a conceptual framework the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool and its domains. We draw on our experiences implementing the Care of Persons with Dementia in their Environments (COPE) program in a statewide Medicaid HCBS setting to highlight how these potential ePCT partners can help optimize pragmatic approaches to several PRECIS-2 domains. We found that partners are especially effective in implementing pragmatic ways to determine eligibility for evidence-based dementia care programs; assist with recruitment of eligible individuals; incorporate dementia care interventions into the range of existing HCBSs; and track outcomes relevant to persons living with dementia, caregivers, HCBS providers, and Medicaid insurance stakeholders. We conclude with recommendations for researchers, potential ePCT partners, and policymakers to help facilitate the growth of dementia care ePCTs in Medicaid HCBS settings across the United States.


Assuntos
Demência , Serviços de Assistência Domiciliar , Humanos , Estados Unidos , Medicaid , Serviços de Saúde Comunitária , Assistência de Longa Duração , Demência/terapia
3.
J Appl Gerontol ; 38(9): 1319-1341, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-29165037

RESUMO

Family caregivers play an essential role in long-term services and supports (LTSS). Despite numerous calls for robust caregiver assessment policies to determine needs and treat them as partners in care planning, there has been limited information about whether or how states assess caregiver needs and strengths, or use caregiver information. Using cross-sectional survey data from the 2015 Process Evaluation of the Older Americans Act National Family Caregiver Support Program (NFCSP), this study analyzes caregiver assessment policies and practices in 54 State Units on Aging, 619 Area Agencies on Aging, and 642 local service providers. It examines whether and for what purposes caregiver assessments are used, what domains are included, and how well current policies conform to recommended practice. It also recommends that policy makers who influence NFCSP and other LTSS programs develop caregiver assessment practices using a multidimensional framework including more caregiver-focused domains and utilizing assessment data to measure program outcomes.


Assuntos
Cuidadores/organização & administração , Família , Avaliação das Necessidades , Idoso , Cuidadores/legislação & jurisprudência , Estudos Transversais , Política de Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/organização & administração , Serviços de Saúde para Idosos/legislação & jurisprudência , Serviços de Saúde para Idosos/organização & administração , Humanos , Assistência de Longa Duração , Inquéritos e Questionários , Estados Unidos
4.
Health Aff (Millwood) ; 34(10): 1628-36, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26438737

RESUMO

A centerpiece of federal and state efforts to rebalance long-term services and supports to enhance consumer choice and contain costs, the federal Money Follows the Person Rebalancing Demonstration helps qualified individuals living in institutions make the transition to life in the community. The Connecticut Money Follows the Person program is an unusually rich source of data, with information on the 2,262 people who transitioned to the community under that state's program during 2008-14. Responses to participant surveys completed before and six, twelve, and twenty-four months after transition indicate that, for the majority of respondents who remained in the community, quality of life and life satisfaction improved significantly after transition, and they stayed high. About half of the participants visited hospitals or emergency departments after transition; however, only 14 percent had returned to an institution one year after transition. Predictors of reinstitutionalization included some not previously observed: mental health disability, difficulties with family members before transition, and not exercising choice and control in daily life. These and other findings suggest multiple ways in which policy makers can target efforts to strengthen transition programs that can meaningfully improve people's lives while containing costs.


Assuntos
Pessoas com Deficiência , Instalações de Saúde , Assistência de Longa Duração , Qualidade de Vida , Connecticut , Pessoas com Deficiência/legislação & jurisprudência , Pessoas com Deficiência/reabilitação , Lares para Grupos , Instalações de Saúde/economia , Instalações de Saúde/legislação & jurisprudência , Humanos , Assistência de Longa Duração/economia , Assistência de Longa Duração/legislação & jurisprudência , Assistência de Longa Duração/métodos
5.
Popul Health Manag ; 18(2): 123-30, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25247347

RESUMO

To inform the design of an integrated health and social service program that will better coordinate care for individuals dually eligible for Medicare and Medicaid, a qualitative study was conducted using 13 focus groups. Participants consisted of a purposeful sample of dually eligible individuals (1) aged 65+ years (8 focus groups: N=71), and (2) aged 18-64 years with disabilities (5 focus groups: N=45), recruited in collaboration with the Connecticut Legislature's Medical Assistance Program Oversight Council and numerous community-based agencies across the state. Older adult participants included nursing home residents, community-dwelling healthy individuals and individuals with chronic illness or disability, family members of individuals with chronic illness or disability, and 1 community-dwelling group of Spanish-speakers. Younger adult participants included persons with physical, intellectual/developmental, and/or mental health disabilities, and parents, case managers, nurses, and residential managers of persons with intellectual/developmental disabilities. Through the constant comparative method, results clustered in 4 domains: current experiences, care coordination, consumer protection, and elements of an ideal health care program. Significant findings include difficulty finding providers who accept Medicare/Medicaid, medication management, age and racial/ethnic discrimination, and care coordination. Findings highlight the policy implications of designing a person-centered, coordinated dual coverage system. Desired elements of an ideal system include greater choice in providers of all types, including culturally competent medical and home care providers, increased coordination among medical providers and between medical and home care/social service providers, and a prominent role for pharmacists in counseling participants and in serving as part of care coordination teams. (Population Health Management 2015;18:123-130).


Assuntos
Aconselhamento/economia , Pessoas com Deficiência/reabilitação , Serviços de Assistência Domiciliar/organização & administração , Medicaid/economia , Medicare/economia , Pesquisa Qualitativa , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
6.
Gerontologist ; 54(2): 297-313, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23990621

RESUMO

PURPOSE OF THE STUDY: Little is known about adults' future planning for long-term supports and services (LTSS), and no studies have examined how LTSS planning compares between Baby Boomers and their parents' generation. The primary aim of this study is to examine the potential influences of birth cohort and gender on LTSS planning. Drawing on Andersen's Behavioral Model of Health Services Use, birth cohort and gender are viewed as predisposing characteristics, and several additional predisposing, enabling, and need characteristics are included as independent variables. DESIGN AND METHODS: Cross-sectional design; data obtained from a statewide survey of 2,522 randomly selected Baby Boomers (born between 1946 and 1964) and older adults (born before 1946). RESULTS: Two thirds of respondents expected to need LTSS, but few reported saving for such services. Controlling for other independent variables, compared with older adults, Baby Boomers were significantly more likely to plan to move to an apartment, live in a retirement community or assisted living, and live with an adult child. Conversely, women were more likely than men to report planning to use specific LTSS such as homecare, but specific LTSS plans did not vary by birth cohort. IMPLICATIONS: Policymakers and providers should prepare for a shift in community planning to accommodate the changing plans and expectations of Baby Boomers, large numbers of whom plan to age in existing homes and retirement communities, or live with adult children, with increasing demand for informal family support. The LTSS industry should also adapt to meet the need for formal services, which will likely continue to grow.


Assuntos
Moradias Assistidas/organização & administração , Necessidades e Demandas de Serviços de Saúde , Serviços de Saúde/estatística & dados numéricos , Assistência de Longa Duração/organização & administração , Crescimento Demográfico , Vigilância da População/métodos , Adulto , Connecticut , Estudos Transversais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Apoio Social , Fatores de Tempo
7.
J Aging Soc Policy ; 24(3): 251-70, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22720886

RESUMO

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.


Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Serviços de Assistência Domiciliar/organização & administração , Instituição de Longa Permanência para Idosos/organização & administração , Vida Independente , Casas de Saúde/organização & administração , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Connecticut , Família , Grupos Focais , Avaliação Geriátrica , Humanos , Revisão da Utilização de Seguros , Assistência de Longa Duração/organização & administração , Medicaid/estatística & dados numéricos , Saúde Mental , Fatores Sexuais , Apoio Social , Serviço Social/organização & administração , Fatores de Tempo , Estados Unidos
8.
Gerontologist ; 49(4): 560-9, 2009 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-19491360

RESUMO

PURPOSE: Although prior research suggests that economic, behavioral, and psychosocial factors influence decisions not to purchase long-term care insurance, few studies have examined the interplay among these factors in depth and from the consumer's point of view. This study was intended to further illuminate these considerations, generate hypotheses about non-purchasing decisions, and inform the design of policies that are responsive to concerns and preferences of potential purchasers. DESIGN AND METHOD: Qualitative study using 32 in-depth interviews and 6 focus groups, following a grounded theory approach. RESULTS: Five themes characterize decisions not to purchase long-term care insurance: (a) the determination that a policy is "too costly" reflects highly individualized and complex trade-offs not solely economic in nature, (b) non-purchasers are skeptical about the viability and integrity of private insurance companies and seek an unbiased source of information, (c) family dynamics play an important role in insurance decisions, (d) contemplating personal risk for long-term care triggers psychological responses that have implications for decision making, and (e) non-purchasers feel inadequately informed and overwhelmed by the process of deciding whether to purchase long-term care insurance. IMPLICATIONS: States are seeking to offset escalating Medicaid long-term care expenditures through a variety of policy mechanisms, including stimulating individual purchase of long-term care insurance. Findings suggest that economic incentives such as lowering premiums will be necessary but not sufficient to attract appropriate candidates. Attention to behavioral and psychosocial factors is essential to designing incentives that are responsive to concerns and preferences of potential purchasers.


Assuntos
Tomada de Decisões , Seguro de Assistência de Longo Prazo , Idoso , Connecticut , Feminino , Grupos Focais , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade
9.
J Gerontol B Psychol Sci Soc Sci ; 64(6): 788-98, 2009 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-19318470

RESUMO

OBJECTIVES: Informal caregivers provide the majority of long-term care. This study examined six health and psychosocial outcomes of caregiving, in the context of multiple characteristics of the caregiving situation, in a representative, statewide sample. METHODS: Data came from 4,041 respondents to the 2007 Connecticut Long-Term Care Needs Assessment. Analyses investigated whether caregiving negatively affects depressive symptoms, health, missing work, and social isolation. Logistic regressions tested the independent effects of caregiver characteristics and conditions of the caregiving situation on these health and psychosocial outcomes. RESULTS: Caregivers rate their health better than noncaregivers and do not report more depressive symptoms or social isolation. Living with the care receiver, inadequate income, and care receivers' unmet need for community-based long-term care services relate to multiple negative outcomes. Care receiver memory problems and caregiver/care receiver relationship do not relate to health or psychosocial outcomes when these other factors are considered. DISCUSSION: Caregiving per se does not lead to symptoms of depression, poor health, or social isolation. Many caregivers do need supports in training and education, respite, and physical and mental health care. Such programs should provide outreach to caregivers facing specific stressful conditions, as not all caregivers experience negative consequences.


Assuntos
Cuidadores/psicologia , Efeitos Psicossociais da Doença , Transtorno Depressivo/diagnóstico , Emprego/psicologia , Nível de Saúde , Isolamento Social , Idoso , Idoso de 80 Anos ou mais , Cuidadores/economia , Estudos de Coortes , Connecticut , Demência/diagnóstico , Demência/psicologia , Transtorno Depressivo/psicologia , Emprego/economia , Feminino , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Inquéritos Epidemiológicos , Humanos , Assistência de Longa Duração/psicologia , Assistência de Longa Duração/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida/psicologia , Fatores Sexuais , Fatores Socioeconômicos , Estresse Psicológico/complicações , Estresse Psicológico/psicologia
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