Climate Change Policies and Older Adults: An Analysis of States' Climate Adaptation Plans.

BACKGROUND AND OBJECTIVES: As climate change drives more frequent and intense weather events, older adults face disproportionate impacts, including having the highest mortality rates from storms, wildfires, flooding, and heat waves. State governments are critical in deploying local resources to help address climate change impacts. This policy study analyzes states' climate adaptation plans to assess the methods through which they address the impact of climate change on older adults. RESEARCH DESIGN AND METHODS: This study uses content analysis to analyze available climate change adaptation plans for all U.S. states for strategies designed to increase the resilience of older adults to the impacts of climate change. RESULTS: A total of 19 states have climate adaptation plans, of which 18 describe older adults as a population group with specific health impacts and risk factors. There are 4 categories of adaptation strategies for older adults that includes communications, transportation, housing, and emergency services. State plans vary in terms of the risk factors and adaptation strategies included. DISCUSSION AND IMPLICATIONS: To varying degrees, states' climate change adaptation planning addresses health, social, and economic risks specific to older adults, as well as strategies for mitigating those risks. As global warming continues, collaborations between public and private sectors and across regions will be needed to prevent negative outcomes such as forced relocation and other social and economic disruptions as well as disparate morbidity and mortality.

Extreme Heat Vulnerability Among Older Adults: A Multilevel Risk Index for Portland, Oregon.

BACKGROUND AND OBJECTIVES: Extreme heat is an environmental health equity concern disproportionately affecting low-income older adults and people of color. Exposure factors, such as living in rental housing and lack of air conditioning, and sensitivity factors, such as chronic disease and social isolation, increase mortality risk among older adults. Older persons face multiple barriers to adaptive heat mitigation, particularly those living in historically temperate climates. This study measures two heat vulnerability indices to identify areas and individuals most vulnerable to extreme heat and discusses opportunities to mitigate vulnerability among older adults. RESEARCH DESIGN AND METHODS: We constructed two heat vulnerability indices for the Portland, OR, metropolitan area: one using area scale proxy measures extracted from existing regional data and another at the individual scale using survey data collected following the 2021 Pacific Northwest Heat Dome event. These indices were analyzed using principal component analysis and Geographic Information Systems. RESULTS: Results indicate that the spatial distribution of areas and individuals vulnerable to extreme heat are quite different. The only area found among the most vulnerable on both indices has the largest agglomeration of age- and income-restricted rental housing in the metropolitan area. DISCUSSION AND IMPLICATIONS: Due to spatial variations in heat-related risk at the individual and area scales, measures addressing heat risk should not be spatially uniform. By focusing resources on older adult individuals and areas in particular need of assistance, heat risk management policies can be both highly efficient and cost effective.

"This 'Family Setting' Is Not that Anymore": Rewards and Challenges of Adult Foster Home Owners.

Small residential care settings for older adults and people with disabilities are found throughout the United States. Those with fewer than 25 residents account for half of residential care settings. Adult foster homes (AFH) are under-studied although they provide personal and health-related services to residents, including people with Alzheimer's disease. This qualitative study collected data from 726 AFH owners over four years. Results provide a contemporary perspective on owners' experience of the rewards and challenges of operating a small home. These results are relevant since many residents prefer small settings, and because federal regulatory changes affect AFH policies and practices.

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.

Correlates of Administrator Tenure in US Residential Care Communities.

OBJECTIVE: To determine community- and individual-level correlates of administrator tenure in US residential care communities (RCCs). DESIGN: Secondary data analysis of the 2010 National Survey of Residential Care Facilities designed by the National Center for Health Statistics. Analysis was conducted using Tobit regression. SETTING AND PARTICIPANTS: A nationally representative sample of RCCs in the United States (n = 2302). MEASURES: The outcome measure for this study is RCC administrator tenure. Residential care community characteristics include chain ownership, size, occupancy rate, profit status, years of operation, if the building was purposely constructed as an RCC, Medicaid census, presence of a dementia care unit, and whether administrative staff provided care. Administrator characteristics included age, gender, race/ethnicity, and level of education. RESULTS: Over a quarter of administrators in this sample remained employed with the same RCC for 10 or more years (28%). Chain membership, community size, and presence of a dementia care unit are associated with shorter administrator tenure (P < .001). Communities with greater than 80% occupancy, administrator's age 40+, and Hispanic race/ethnicity were associated with longer administrator tenure (P < .001). CONCLUSIONS/IMPLICATIONS: Various community and administrator characteristics are associated with shorter or longer tenure within the same community. More setting-specific research is needed to identify how RCC administrators influence care quality and what different lengths of tenure indicate in the context of RCC operations.

The Impact of Communication Impairments on the Social Relationships of Older Adults: Pathways to Psychological Well-Being.

Purpose Social contact is known to be vital for older adults' mental and physical health but, because communication impairments often co-occur with other types of disability, it is difficult to generalize about the relative impact of a communication impairment on the social relationships of older adults. Specific aims of the study were to examine whether the severity of a communication impairment was associated with a range of social measures and to examine the association between these characteristics and psychological well-being. Method Community-dwelling older adults ranging in age from 65 to 94 were recruited for the study of Communication, Health, Aging, Relationship Types and Support. The sample included 240 participants with communication disorders arising from a variety of etiologies including hearing impairment, voice disorders, head and neck cancer, and neurologic disease, as well as older adults without a communication disorder. Results Communication impairment was a significant independent predictor for key characteristics of social relationships, including the number of friends in the social network, two types of social support, the frequency of social participation, and social self-efficacy. Communication impairment was also a significant predictor for higher levels of loneliness and depression. In addition, two distinct pathways between communication impairment and psychological well-being were identified, with social self-efficacy and reassurance of worth as mediators. Conclusions Even after controlling for age, gender, health, and disability, communication impairment is a significant independent predictor for key aspects of the social function of older adults and demonstrates two distinct pathways to loneliness and depression. Supplemental Material https://doi.org/10.23641/asha.7250282.

State Regulatory Approaches for Dementia Care in Residential Care and Assisted Living.

Purpose: This policy study analyzed states' residential care and assisted living (RC/AL) regulations for dementia care requirements. Estimates suggest that at least half of RC/AL residents have dementia, and 22% of settings provide or specialize in dementia care. Residents with dementia might benefit from regulations that account for specific behaviors and needs associated with dementia, making states' RC/AL regulations address dementia care an important policy topic. Design and Methods: This study examined RC/AL regulations in all 50 states and the District of Columbia for regulatory requirements on five topics important to the quality of life of RC/AL residents with dementia: pre-admission assessment, consumer disclosure, staffing types and levels, administrator training, and physical environment. Results: Sixteen states license or certify dementia care units within RC/AL settings. All states had at least one dementia care requirement, though only four states had requirements for all five of the topics reviewed. Most states addressed administrator training, consumer disclosure, and physical environment, 17 addressed staffing types and levels, and 14 addressed pre-admission assessment for dementia. Thus, most states rely on general RC/AL regulations to cover dementia care policies and practices. Implications: This policy study provides a resource for researchers who do cross-state studies of dementia care in RC/AL settings and state policymakers who are updating RC/AL regulations, including those responding to a 2014 Centers for Medicare and Medicaid Services rule change.

State Regulation of Medication Administration by Unlicensed Assistive Personnel in Residential Care and Adult Day Services Settings.

Residential care settings and adult day services are two community-based care options used by older adults with chronic health conditions. Most states have regulatory provisions that allow unlicensed assistive personnel (UAP) to administer medications. The current national policy study examined state regulations to identify which states permit UAP to administer medications, as well as staffing and training requirements. Key findings include states lack clear and adequate provisions for nurse oversight of UAP who administer medications, although adult day service regulations provide a greater level of nurse oversight than residential care settings. Specifically, 32 states require residential care to hire a nurse, but only six include provisions regarding nurse availability (e.g., on-call, on-site, number of hours). In contrast, 10 of 20 states that require adult day service programs to hire a nurse provide availability provisions. Nurse oversight of UAP is an important means of assuring quality care and reducing errors; thus, state regulatory agencies might need to strengthen nurse oversight provisions. [Res Gerontol Nurs. 2016; 9(5):209-222.].

Direct care worker's perceptions of job satisfaction following implementation of work-based learning.

The purpose of this study was to understand the impact of a work-based learning program on the work lives of Direct Care Workers (DCWs) at assisted living (AL) residences. The research questions were addressed using focus group data collected as part of a larger evaluation of a work-based learning (WBL) program called Jobs to Careers. The theoretical perspective of symbolic interactionism was used to frame the qualitative data analysis. Results indicated that the WBL program impacted DCWs' job satisfaction through the program curriculum and design and through three primary categories: relational aspects of work, worker identity, and finding time. This article presents a conceptual model for understanding how these categories are interrelated and the implications for WBL programs. Job satisfaction is an important topic that has been linked to quality of care and reduced turnover in long-term care settings.

Age-Friendly Portland: a university-city-community partnership.

This article addresses the question of how creating an age-friendly city has come to be an important policy and planning issue in Portland, Oregon. In 2006, researchers from Portland State University's Institute on Aging examined the meanings of age friendliness among a broad range of participants in Portland, Oregon. The research was conducted in conjunction with the World Health Organization's (WHO) Age-Friendly Cities project and followed the completion of two earlier non-WHO-related projects. The city of Portland, through the Institute on Aging, was one of nine original members to apply for and be accepted into the WHO Global Network of Age-Friendly Cities and Communities. An Age-Friendly Portland Advisory Council was formed to guide the development of an action plan, monitor progress over time, and suggest additional research. To understand how Portland's age-friendly policy effort has developed over time, we use Kingdon's (1984) agenda-setting framework to explain how the policy problem was formulated, how solutions were developed, and the influence of local politics. The policy actors, including individuals and organizations working within and outside of government, are described. The Portland experience provides a case study that other cities, especially those with a strong commitment to community-engaged urban planning, may find useful as they develop age-friendly initiatives.

"Learning about your residents": how assisted living residence medication aides decide to administer pro re nata medications to persons with dementia.

PURPOSE: This study identified how unlicensed staff members decide to administer medications prescribed pro re nata (PRN) to residents of assisted living (AL) settings designated for persons with dementia. Theories of knowledge, including explicit and implicit knowledge, discretion, and judgment, guided the analysis. DESIGN AND METHODS: Data were collected and analyzed using qualitative methods. The staff members responsible for medication administration were shadowed for 6 consecutive days in three Oregon ALs. In-person interviews were conducted with 16 staff members, and residents' medication records were reviewed. RESULTS: Medication aides' decisions to administer PRN medications were informed by resident request, interpretation of resident-specific actions, training and experience, and setting-specific practices. The theme, learning about your residents, was consistent across settings. IMPLICATIONS: By administering PRN medications, medication aides play an important role in the daily care and comfort of AL residents with dementia. Policy makers need information about whether to permit unlicensed staff to administer medications and the level of training to require. This research suggests that training should recognize the tacit knowledge of practicing medication aides. Despite the role that PRN medications can play in the daily comfort and well-being of AL residents, little is known about as-needed medications prescribed versus those actually used across settings; also needed is an understanding of how other health professionals are involved in treatment plans that include medications.

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

OBJECTIVES: To compare rates of medication errors committed by assisted living staff with different training and to examine characteristics of errors. DESIGN: Observation of medication preparation and passes, chart review, interviews, and questionnaires. SETTING: Stratified random sample of 11 assisted living communities in South Carolina (which permits nonnurses to administer medications) and Tennessee (which does not). PARTICIPANTS: All staff who prepared or passed medications: nurses (one registered nurse and six licensed practical nurses (LPNs)); medication aides (n=10); and others (n=19), including those with more and less training. MEASUREMENTS: Rates of errors related to medication, dose and form, preparation, route, and timing. RESULTS: Medication preparation and administration were observed for 4,957 administrations during 83 passes for 301 residents. The error rate was 42% (20% when omitting timing errors). Of all administrations, 7% were errors with moderate or high potential for harm. The odds of such an error by a medication aide were no more likely than by a LPN, but the odds of one by staff with less training was more than two times as great (odds ratio=2.10, 95% confidence interval=1.27-3.49). A review of state regulations found that 20 states restrict nonnurses to assisting with self-administration of medications. CONCLUSION: Medication aides do not commit more errors than LPNs, but other nonnurses who administered a significant number of medications and assisted with self-administration committed more errors. Consequently, all staff who handle medications should be trained to the level of a medication aide.

Understanding the intersection of individual needs and choices with organizational practices: the case of medication management in assisted living.

PURPOSE: Making choices about everyday activities is a normal event for many adults. However, when an adult moves into an assisted living (AL) community, making choices becomes complicated by perceived needs and community practices. This study examines the relationship between choice and need in the context of practices, using medication administration practices as the case in point. DESIGN AND METHODS: A 5-year ethnographic study collected information from 6 AL settings in Maryland. Ethnographic interviews (n = 323) and field notes comprise the data described in this article. RESULTS: AL organizations used practice rationales based on state regulations, professional responsibility, safety concerns, and social model values to describe and explain their setting-specific practices. The result was varying levels of congruence between the setting's practices and individual resident's needs and choices. That is, in some cases, the resident's needs were lost to the organization's practices, and in other cases, organizations adapted to resident need and choices. These findings suggest that individuals and organizations adapt to each other, resulting in practices that are not bound by state requirement or other practice rationales. IMPLICATIONS: AL residences vary due to both internal and external forces, not just the public policies that define them. State regulations need to be responsive to both the needs and the choices of individual residents and to the people who work in an AL.

Consumer discourse in assisted living.

OBJECTIVES: The aim of this article is to discuss the cultural construction of the assisted living consumer. Based on theories of consumer studies, it focuses on organizational strategies employed by assisted living practitioners to promote consumer choice and independence while mediating potential risks. METHODS: Data include field notes, participation in manager-training programs, and interviews with residents and family members during a 22-month study of three Oregon facilities. RESULTS: Consumer discourse is evident in four primary sources, including the state rules, manager-training programs, organizational practices, and an institutional belief in specific consumer demands like independence and choice. DISCUSSION: Personal care is a complex consumer "good" further complicated by residents with cognitive impairments, family demands, payment sources, and the very novelty of the assisted living philosophy. We conclude with a discussion of benefits and pitfalls based on the use of consumer discourse that represents older persons as active consumers, rather than recipients, of long-term care services.

A comparison of two methods for identifying frail Medicare-aged persons.

This article compares the efficacy of two screening methods to identify frail Medicare-aged persons using self-report questionnaire data: a clinical judgment method developed by nurse and social worker professionals in a community-based long-term care department and an empirical research method previously developed by the Center for Health Research using computer formulas and stepwise logistic regression coefficients. A sub-aim was to see whether the empirical method proved robust over time by measuring aggregate utilization and mortality in frail and nonfrail cohorts, which would increase the interest of physicians, managed care organizations, and other agencies providing service to Medicare beneficiaries.