Disparities in COVID-19-Related Mortality Among Older Adults With Alzheimer's Disease and Related Dementias: Variations Over Time.

Older adults with Alzheimer's disease and related dementias (ADRD) had a high risk of COVID-19-related mortality. Racial and ethnic minorities were disproportionally impacted by the pandemic. The variations in disparities, including racial and ethnic disparities and disparities across communities, in COVID-19-related mortality across the different stages of the COVID-19 pandemic among the ADRD population are unknown. This observational study estimated linear probability models for community-dwelling older adults with ADRD who were diagnosed with COVID-19 in 2020 and 2021 using multiple national data (e.g., Medicare data), accounting for individual and community characteristics. Disparities in 30-day mortality were compared between 2020 and 2021. The socioeconomic disparity in COVID-19-related mortality across communities became insignificant during the later stage of the pandemic, ethnic differences in COVID-19-related mortality decreased but persisted, and racial disparity remained largely unchanged. The study provides insights into interventions to mitigate lingering disparities in health outcomes among the vulnerable population.

Telemedicine Utilization Among Residents With Alzheimer Disease and Related Dementia: Association With Nursing Home Characteristics.

OBJECTIVE: To examine telemedicine use among nursing home (NH) residents with Alzheimer disease and related dementias (ADRD) and the associations with NH characteristics. DESIGN: Observational study. SETTING AND PARTICIPANTS: 2020-2021 Minimum Data Set 3.0, Medicare datasets, and Nursing Home Compare data were linked. A total of 10,810 NHs were identified. METHODS: The outcome variable was the percentage of residents with ADRD who used telemedicine in an NH in a quarter. The main independent variables were NH racial and ethnic compositions (ie, percentages of Black and Hispanic residents) and NH rurality. A set of linear models with NH random effects were estimated. The analysis was stratified by COVID-19 pandemic stages, including the beginning of the pandemic [second quarter of 2020 (2020 Q2)], before and after the widespread of the COVID-19 vaccine (ie, 2020 Q3-2021 Q1 and 2021 Q2-2021 Q4). RESULTS: The proportion of residents with ADRD in NHs who had telemedicine use declined from 35.0% in 2020 Q2 to 9.3% in 2021 Q4. After adjusting for other NH characteristics, NHs with a high proportion of Hispanic residents were 2.7 percentage points more likely to use telemedicine for residents with ADRD than those with a low proportion during 2021 Q2-2021 Q4 (P < .001), whereas NHs with a high proportion of Black residents were 1.5 percentage points less likely to use telemedicine than those with a low proportion (P < .01). Additionally, compared with metropolitan NHs, rural NHs were 6.4 percentage points less likely to use telemedicine in 2020 Q2 (P < .001), but 5.9 percentage points more likely to use telemedicine during 2021 Q2-2021 Q4 (P < .001). We also detected the relationship between telemedicine use and other NH characteristics, such as NH quality, staffing level, and Medicaid-pay days. CONCLUSIONS AND IMPLICATIONS: The proportion of residents with ADRD in NHs who had telemedicine use decreased during the pandemic. Telemedicine could improve health care access for NHs with a high proportion of Hispanic residents and NHs in remote areas. Future studies should investigate how telemedicine use affects the health outcomes of NH residents with ADRD.

Racial and ethnic differences in telemedicine use among community-dwelling older adults with dementia.

BACKGROUND: Routine ambulatory care is essential for older adults with Alzheimer's disease and related dementias (ADRD) to manage their health conditions. The federal government expanded telemedicine coverage to mitigate the impact of the COVID-19 pandemic on ambulatory services, which may provide an opportunity to improve access to care. This study aims to examine differences in telemedicine use for ambulatory services by race, ethnicity, and community-level socioeconomic status among community-dwelling older adults with ADRD. METHODS: This retrospective cohort study used Medicare claims data between April 01, 2020 and December 31, 2021. We included community-dwelling Medicare fee-for-service beneficiaries aged 65 years and older with ADRD. The outcome variable is individual's use (yes/no) of telemedicine evaluation and management (tele-EM) visits in each quarter. The key independent variables are race, ethnicity, and community-level socioeconomic status. RESULTS: The analytical sample size of the study was 2,068,937, including 9.9% Black, 82.7% White, and 7.4% Hispanic individuals. In general, we observed a decreasing trend of tele-EM use, and the average rate of quarterly tele-EM use was 23.0%. Tele-EM utilization varied by individual race, ethnicity, and community-level socioeconomic status. On average, White and Black individuals in deprived communities were 3.5 and 2.4 percentage-points less likely to use tele-EM compared with their counterparts in less-deprived communities (p < 0.001). However, Hispanic individuals in deprived communities were 2.4 percentage-points more likely to utilize tele-EM compared with those in less-deprived communities (p < 0.001). Additionally, we observed various racial and ethnic differences in telemedicine use in deprived communities versus less-deprived communities. CONCLUSIONS: We observed various racial and ethnic differences in telemedicine use, both within and between communities by socioeconomic status. Telemedicine is a viable healthcare delivery option that may influence healthcare access for racial and ethnic minorities and for individuals in socioeconomically deprived communities. Further policies or interventions may be needed to ensure all individuals have equal access to newly available care delivery models.

Home Health Quality among Hospitalized Older Adults with Alzheimer's Disease and Related Dementia: Association with Race/Ethnicity and Dual Eligibility before and during the COVID Pandemic.

OBJECTIVES: During the COVID-19 pandemic, home health agencies (HHAs) discharges following acute hospitalizations increased. This study examined whether racial and ethnic minoritized and socioeconomically disadvantaged patients (ie, Medicare-Medicaid dual-eligible) were differentially discharged to below-average quality HHAs before and during the COVID-19 pandemic. We focused on post-acute patients with Alzheimer's disease and related dementias (ADRD), who are generally frail and have high care needs. DESIGN: Cohort study. SETTING AND PARTICIPANTS: We linked 2019 to 2021 Medicare data with Area Deprivation Index (ADI), Home Health Compare, and COVID-19 infection data. We included Medicare beneficiaries with ADRD who were hospitalized for non-COVID-19 conditions and discharged to HHAs between January 2019 and November 2021. The final analytical sample included 426,766 qualified hospitalization events. METHODS: The outcome variable was whether a patient received care from a below-average quality HHA, defined by an average Quality of Patient Care Star Rating lower than 3.0. Key independent variables included individual race, ethnicity, and Medicare-Medicaid dual status. Linear probability models with county fixed effects were estimated, sequentially adjusting for the individual- and community-level covariates. Sensitivity analysis using various definitions of below-average quality HHAs was conducted. RESULTS: Before the pandemic, Black and Hispanic individuals had significantly higher probabilities of discharge to below-average quality HHAs compared with white individuals (3.4 and 3.9 percentage points, respectively). Dual-eligible individuals were also 2.5 percentage points more likely to be discharged to below-average quality HHAs. During the pandemic, disparities in being discharged to below-average quality HHAs persisted among racial and ethnic minoritized patients and increased among duals. Findings were consistent with and without adjusting for individual covariates and across different definitions of below-average quality HHA. CONCLUSIONS AND IMPLICATIONS: Persistent disparities were observed in being discharged to below-average quality HHAs by race, ethnicity, and dual status. Further research is needed to identify factors contributing to these ongoing inequalities.

Telemedicine and Disparities in Mental Health Service Use Among Community-Dwelling Older Adults With Alzheimer Disease and Related Dementias.

OBJECTIVE: To examine disparities in mental health (MH) service utilization, via in-person and telemedicine (ie, tele-MH), by individuals' race, ethnicity, and community socioeconomic status, among community-dwelling older adults with Alzheimer disease and related dementias (ADRD) before and after the expansion of the Centers for Medicare and Medicaid Services' (CMS's) telemedicine policy. DESIGN: Observational study. SETTING AND PARTICIPANTS: A total of 3,003,571 community-dwelling Medicare beneficiaries with ADRD between 2019 and 2021 were included in the study. METHODS: Multiple national data were linked. The unit of analysis was individual-quarter. Three outcomes were defined: any MH visits (in-person or tele-MH), in-person MH visits, and tele-MH visits per quarter. Key independent variables included individual race and ethnicity, the socioeconomic status of the community, and an indicator for the implementation of the telemedicine policy. Regression analyses with individual random effects were used. RESULTS: In general, Black and Hispanic older adults with ADRD and those in socioeconomically deprived communities were less likely to have MH visits than white adults and those from less-deprived communities. In-person and tele-MH visits varied throughout the pandemic and across subpopulations. For instance, at the beginning of the pandemic, white, Black, and Hispanic older adults experienced 5.05, 3.03, and 2.87 percentage point reductions in in-person MH visits, and 3.53, 1.26, and 0.32 percentage point increases in tele-MH visits (with P < .01 for racial/ethnic differences), respectively. During the pandemic, the increasing trend in in-person MH visits and the decreasing trend in tele-MH visits varied across different subgroups. Overall, racial and ethnic differences in any MH visits were reduced, but the gap in any MH visits between deprived and less-deprived communities doubled during the pandemic (P < .01). CONCLUSIONS AND IMPLICATIONS: Telemedicine may have provided an opportunity to improve access to MH services among underserved populations. However, although some disparities in MH care were reduced, others widened, underscoring the importance of equitable health care access strategies to address the unique needs of different populations.

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement.

OBJECTIVES: Assess prevalence of serious mental illness (SMI) alone, and co-occurring with Alzheimer disease and related dementias (ADRD), among Medicare beneficiaries in assisted living (AL). Examine the association between permanent nursing home (NH) placement and SMI, among residents with and without ADRD. DESIGN: 2018-2019 retrospective cohort of Medicare beneficiaries in AL. Residents were followed for up to 2 years to track their NH placement. We used data from the Medicare Enrollment Database, the Medicare Beneficiary Summary File, Minimum Data Set, and a national directory of state-licensed AL communities. AL residents were identified using a validated, previously reported 9-digit zip code methodology. SETTING AND PARTICIPANTS: A cross-sectional study sample included 289,350 Medicare beneficiaries in 17,265 AL communities across 50 states and in the District of Columbia. METHODS: The outcome was permanent NH placement: a continuous stay for more than 90 days. Key independent variable was presence of SMI-schizophrenia, bipolar disorder, and major depression. Other covariates included sociodemographic factors and presence of other chronic conditions, including ADRD. A linear probability model with robust SEs, and AL-level random effects, was used to test the association between SMI diagnoses, ADRD, and their interactions on NH placement. RESULTS: More than half (55.65%) of AL residents had a diagnosis of SMI, among them 93.2% had major depression, 28.5% schizophrenia, and 22.2% bipolar disorder. Individuals with schizophrenia and bipolar disorder had a significantly lower probability of NH placement, a 32% and a 15% decrease relative to the cohort mean, respectively. Placement risk was significantly greater for residents with ADRD compared to those without, increasing for those who also had schizophrenia or bipolar disorder, 12.9% and 1.5% relative to the sample mean, respectively. CONCLUSION AND IMPLICATIONS: Presence of schizophrenia and bipolar disorder, in conjunction with ADRD, significantly increases the risk of long-term NH placement, suggesting that ALs may not be well prepared to care for these residents.

Assisted living residents with dementia: Disparities in mental health services pre and during COVID-19.

BACKGROUND: Little is known about mental health among Medicare beneficiaries with Alzheimer's disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL residents with ADRD, pre and during the COVID pandemic, focusing on race/ethnicity and Medicare/Medicaid dual status. METHODS: A CY2018 cohort of AL residents with ADRD was identified. Outcome was any quarterly in-person or telemedicine mental health visit based on national CY2019-2020 Medicare claims. Key independent variables were individual race/ethnicity and dual status and the AL-level proportion of dual residents. We estimated a linear probability model with random effects and robust standard errors. Quarterly indicators captured service use before and after the onset of the pandemic. RESULTS: The study included 102,758 fee-for-service Medicare beneficiaries with ADRD in 13,400 ALs. One in five residents had any mental health visits prior to the COVID-19 pandemic. Black residents, and those with dual Medicare/Medicaid eligibility, were significantly less likely to use mental health services prior to and during the pandemic. There were no significant differences in visits via telemedicine by race/ethnicity or individual dual status. Residents in AL communities with a higher proportion of duals had a lower likelihood of visits before and during the pandemic. CONCLUSIONS/IMPLICATIONS: Mental health service use among AL residents with ADRD was low and declining prior to the pandemic. Telehealth allowed for mental health visits to continue during the pandemic, albeit at a lower level. Residents in ALs with a higher proportion of duals were less likely to have in-person or telehealth visits. The results suggest that some ALs may find it difficult to assure mental health service provision to this vulnerable population.

Outcomes After Community Discharge From Skilled Nursing Facilities: The Role of Medicaid Home and Community-Based Services.

This study investigated the association between Medicaid Home and Community-Based Services (HCBS) generosity and post-discharge outcomes among dual-eligible beneficiaries discharged from skilled nursing facilities (SNFs). We linked multiple national datasets for duals discharged from SNFs between 2010 and 2013. Accounting for SNF fixed effects, we estimated the effect of HCBS generosity, measured by its breadth and intensity, on the likelihood of remaining in the community, risks of death, nursing home (NH) admission, and hospitalizations within 30 and 180 days after SNF discharge. We found that higher HCBS generosity was associated with an increased likelihood of remaining in the community. HCBS breadth and intensity were both significantly associated with reduced risks of NH admission, while higher HCBS intensity was related to a reduced risk of acute hospitalizations within 30 days after discharge. Our findings suggest that more generous HCBS programs may facilitate smoother transitions and sustainable community living following SNF discharge.

Post-acute care transitions during COVID-19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia.

BACKGROUND: Differences in the post-acute care (PAC) destinations among racial, ethnic, and socioeconomic groups have been documented before the COVID-19 pandemic. Yet, the pandemic's impact on these differences remains unknown. We examined the impact of the COVID-19 pandemic on PAC destinations and its variation by individual race, ethnicity, and socioeconomic status among community-dwelling older adults with Alzheimer's disease and related dementia (ADRD). METHODS: We linked 2019-2021 national data (Medicare claims, Minimum Data Set, Master Beneficiary Summary File) and several publicly available datasets, including Provider of Services File, Area Deprivation Index, Area Health Resource File, and COVID-19 infection data. PAC discharge destinations included skilled nursing facilities (SNFs), home health agencies (HHA), and homes without services. Key variables of interest included individual race, ethnicity, and Medicare-Medicaid dual status. The analytic cohort included 830,656 community-dwelling Medicare fee-for-service beneficiaries with ADRD who were hospitalized between 2019 and 2021. Regression models with hospital random effects and state-fixed effects were estimated, stratified by the time periods, and adjusted for the individual, hospital, and county-level covariates. RESULTS: SNF discharges decreased while home and HHA discharges increased during the pandemic. The trend was more prominent among racial and ethnic minoritized groups and even more so among dual-eligible beneficiaries. For instance, the reduction in the probabilities of SNF admissions between the pre-pandemic period and the 2nd year of COVID was 4.6 (White non-duals), 18.5 (White duals), 8.7 (Black non-duals), and 20.1 (Black duals) percentage-point, respectively. We also found that non-duals were more likely to replace SNF with HHA services, while duals were more likely to be discharged home without HHA. CONCLUSIONS: The COVID-19 pandemic significantly impacted PAC destinations for individuals with ADRD, especially among socioeconomically disadvantaged and racial and ethnic minoritized populations. Future research is needed to understand if and how these transitions may have affected health outcomes.

Hospice providers serving assisted living residents: Association of higher volume with lower quality.

BACKGROUND: Assisted living (AL) community caregivers are known to report lower quality of hospice care. However, little is known about hospice providers serving AL residents and factors that may contribute to, and explain, differences in quality. We examined the association between hospice providers' AL patient-day volume and their quality ratings based on Hospice Item Set (HIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Surveys. METHODS: This cross-sectional study employed information from the Medicare Compare website and Medicare claims data. Medicare-eligible AL residents were identified using previously validated methods and merged with hospice claims. Linear probability models adjusting for county fixed effects were used to examine the association between hospice provider AL volume, measured as the share of annual hospice patient days from AL residents, and quality measures obtained from HIS and CAHPS. Models controlled for hospice providers' profit status and daily patient census. RESULTS: Higher AL-volume hospice providers were 7 percentage points more likely to have caregivers reporting lower median scores on domains of pain assessment, dyspnea treatment, and emotional support. Their caregivers also reported lower scores in team communications and training family to provide care. Higher AL-volume hospice providers also were 5 percentage points less likely to get higher aggregated scores from all CAHPS domains and 7 percentage points less likely to have higher HIS composite scores. CONCLUSIONS: Hospice providers serving higher volumes of AL patient days had lower quality scores. In order to identify targeted opportunities for quality improvement, research is needed to understand why lower quality providers are concentrated in the AL market.

Home time and state regulations among Medicare beneficiaries in assisted living communities.

BACKGROUND: Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed nurse staffing. METHODS: Medicare beneficiaries who entered AL communities in 2018 were identified, and their home time in the year following admission was measured. Home time was calculated as the percentage of time spent at home per day being alive. Resident characteristics and state regulations in DCW staffing, DCW training, and licensed staffing were measured. We used a multivariate linear regression model with AL-level fixed effects to estimate the relationship between person-level characteristics and home time. Linear regression models adjusting for resident characteristics were used to estimate the association between state regulations and residents' home time. RESULTS: The study sample included 59,831 new Medicare beneficiary residents in 12,143 ALs. In the year following AL admission, residents spent 94% (standard deviation = 14.6) of their time at home. Several resident characteristics were associated with lower home time: Medicare-Medicaid dual eligibility, having more chronic conditions, and specific chronic conditions, for example, dementia. In states with greater regulatory specificity for DCW training and staffing, and lower specificity for licensed staffing, residents had longer adjusted home time. CONCLUSION/IMPLICATIONS: Home time varied substantially among AL residents depending on resident characteristics and state-level regulatory specificity. AL residents eligible for Medicare and Medicaid had substantially shorter home time than the Medicare-only residents, largely due to longer time spent in nursing homes. State AL regulatory specificity for DCWs and licensed staff also impacted AL residents' home time. These findings may guide AL operators and state legislators in efforts to improve this important quality of life metric.

Did Minimum Wage Policy Changes Impact Home Health Workforce?

The shortage of home health aides has been exacerbated in recent years partially because of low wages. Minimum wage (MW) policy changes may alleviate this workforce shortage. This study examined the effects of MW policies on wages and employment of home health aides. We performed a county-level longitudinal analysis using 2012 to 2018 national data. The study cohort included 2,496 counties and focused on all workers in the home health industry. Outcome variables included wages and the employment of home health aides. Key variables of interest included the consumer price index adjusted state MW and a set of variables that captured the effect of the Fair Labor Standards Act (FLSA) extension. This study found that home health aides' hourly wages were $1.00 higher (p = .011) in states that increased their MWs from below $8 to above $10. The FLSA extension was associated with $1.15 higher wages in states with higher MWs (i.e., state MW above $10 in 2014). The FLSA extension was associated with higher employment of home health aides in less-competitive markets, rather than high- or average-competitive markets. This study suggests that state MW increases combined with the FLSA extension may help maintain the current home health workforce and improve their wages.

Assisted living or nursing home: Who is moving in?

BACKGROUND: Despite the rapid growth of assisted living (AL) communities and the increasing similarity between AL and nursing home (NH) populations, little is known about the characteristics of older adults at the time of AL admission and how these characteristics compare to individuals newly admitted to NH from the community. This study examined the individual, facility, and geographic factors associated with new AL admission. METHODS: This retrospective descriptive study used data from the national Medicare enrollment and claims datasets, the Minimum Data Set, and the Medicare Provider Analysis and Review. The study cohort included 158,124 Medicare beneficiaries newly admitted to ALs and 715,261 newly admitted to NHs during 10/2017-10/2019. Multinomial logistic regression analysis and logistic regression analysis were conducted to examine factors associated with new admissions. RESULTS: Demographic, socioeconomic, and health service use characteristics were associated with new admission to long-term care. Specifically, Medicare fee-for-service beneficiaries, those age 75 years and older, male, having one skilled nursing facility (SNF) stay or any hospital stay in the past 6 months are more likely to be newly admitted to AL, whereas those who are dually eligible, racial/ethnic minorities, and having two or more SNF stays in the past 6 months are more likely to be admitted to an NH. CONCLUSION: There are substantial differences between individuals who are newly admitted from the community to AL versus those to NH.

Hospital Proximity and Emergency Department Use among Assisted Living Residents.

OBJECTIVES: To examine the relationship between AL communities' distance to the nearest hospital and residents' rates of emergency department (ED) use. We hypothesize that when access to an ED is more convenient, as measured by a shorter distance, assisted living (AL)-to-ED transfers are more common, particularly for nonemergent conditions. DESIGN: Retrospective cohort study, where the main exposure of interest was the distance between each AL and the nearest hospital. SETTING AND PARTICIPANTS: 2018-2019 Medicare claims were used to identify fee-for-service Medicare beneficiaries aged ≥55 years residing in AL communities. METHODS: The primary outcome of interest was ED visit rates, classified into those that resulted in an inpatient hospital admission and those that did not (ie, ED treat-and-release visits). ED treat-and-release visits were further classified, based on the NYU ED Algorithm, as (1) nonemergent; (2) emergent, primary care treatable; (3) emergent, not primary care treatable; and (4) injury-related. Linear regression models adjusting for resident characteristics and hospital referral region fixed effects were used to estimate the relationship between distance to the nearest hospital and AL resident ED use rates. RESULTS: Among 540,944 resident-years from 16,514 AL communities, the median distance to the nearest hospital was 2.5 miles. After adjustment, a doubling of distance to the nearest hospital was associated with 43.5 fewer ED treat-and-release visits per 1000 resident years (95% CI -53.1, -33.7) and no significant difference in the rate of ED visits resulting in an inpatient admission. Among ED treat-and-release visits, a doubling of distance was associated with a 3.0% (95% CI -4.1, -1.9) decline in visits classified as nonemergent, and a 1.6% (95% CI -2.4%, -0.8%) decline in visits classified as emergent, not primary care treatable. CONCLUSIONS AND IMPLICATIONS: Distance to the nearest hospital is an important predictor of ED use rates among AL residents, particularly for visits that are potentially avoidable. AL facilities may rely on nearby EDs to provide nonemergent primary care to residents, potentially placing residents at risk of iatrogenic events and generating wasteful Medicare spending.

Racial/Ethnic Differences in Risk Factors Associated With Severe COVID-19 Among Older Adults With ADRD.

OBJECTIVE: To examine racial/ethnic differences in risk factors, and their associations with COVID-19-related outcomes among older adults with Alzheimer's disease and related dementias (ADRD). DESIGN: Observational study. SETTING AND PARTICIPANTS: National Medicare claims data and the Minimum Data Set 3.0 from April 1, 2020, to December 31, 2020, were linked in this study. We included community-dwelling fee-for-service Medicare beneficiaries with ADRD, diagnosed with COVID-19 between April 1, 2020, and December 1, 2020 (N = 138,533). METHODS: Two outcome variables were defined: hospitalization within 14 days and death within 30 days of COVID-19 diagnosis. We obtained information on individual sociodemographic characteristics, chronic conditions, and prior health care utilization based on the Medicare claims and the Minimum Dataset. Machine learning methods, including lasso regression and discriminative pattern mining, were used to identify risk factors in racial/ethnic subgroups (ie, White, Black, and Hispanic individuals). The associations between identified risk factors and outcomes were evaluated using logistic regression and compared across racial/ethnic subgroups using the coefficient comparison approach. RESULTS: We found higher risks of COVID-19-related outcomes among Black and Hispanic individuals. The areas under the curve of the models with identified risk factors were 0.65 to 0.68 for mortality and 0.61 to 0.62 for hospitalization across racial/ethnic subgroups. Although some identified risk factors (eg, age, gender) for COVID-19-related outcomes were common among all racial/ethnic subgroups, other risk factors (eg, hypertension, obesity) varied by racial/ethnic subgroups. Furthermore, the associations between some common risk factors and COVID-19-related outcomes also varied by race/ethnicity. Being male was related to 138.2% (95% CI: 1.996-2.841), 64.7% (95% CI: 1.546-1.755), and 37.1% (95% CI: 1.192-1.578) increased odds of death among Hispanic, White, and Black individuals, respectively. In addition, the racial/ethnic disparity in COVID-19-related outcomes could not be completely explained by the identified risk factors. CONCLUSIONS AND IMPLICATIONS: Racial/ethnic differences were detected in the likelihood of having COVID-19-related outcomes, specific risk factors, and relationships between specific risk factors and COVID-19-related outcomes. Future research is needed to elucidate the reasons for these differences.

Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter?

OBJECTIVE: To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies. DESIGN: Retrospective cross-sectional study. SETTING AND PARTICIPANTS: The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017. METHODS: 2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies. RESULTS: Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01). CONCLUSIONS AND IMPLICATIONS: Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations.

OBJECTIVE: We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations. DESIGN: Cohort study. SETTING AND PARTICIPANTS: Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662). METHODS: We used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics. RESULTS: End-of-life care transitions were observed among 34.89% of our study sample in the last 30 days before death, and among 17.25% in the last 7 days. Higher frequency of care transitions in the last 7 days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR) = 1.08; P = .002] and direct care worker staffing (IRR = 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR = 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR = 1.15; P < .0001) and training (IRR = 0.79; P < .001) and transitions within 30 days of death. CONCLUSIONS AND IMPLICATIONS: There were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30 days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.

Online Customer Reviews of Assisted Living Communities: Association with Community, County, and State Factors.

OBJECTIVES: Online reviews provided by users of assisted living communities may offer a unique source of heretofore unexamined data. We explored online reviews as a possible source of information about these communities and examined the association between the reviews and aspects of state regulations, while controlling for assisted living, county, and state market-level factors. DESIGN: Cross-sectional, observational study. SETTING AND PARTICIPANTS: Sample included 149,265 reviews for 8828 communities. METHODS: Primary (eg, state regulations) and secondary (eg, Medicare Beneficiary Summary Files) data were used. County-level factors were derived from the Area Health Resource Files, and state-level factors from the integrated Public Use Microdata series. Information on state regulations was obtained from a previously compiled regulatory dataset. Average assisted living rating score, calculated as the mean of posted online reviews, was the outcome of interest, with a higher score indicating a more positive review. We used word cloud to visualize how often words appeared in 1-star and 5-star reviews. Logistic regression models were used to determine the association between online rating and a set of community, county, and state variables. Models were weighted by the number of reviews per assisted living bed. RESULTS: Overall, 76% of communities had online reviews. We found lower odds of positive reviews in communities with greater proportions of Medicare/Medicaid residents [odds ratio (OR) = 0.986; P < .001], whereas communities located in micropolitan areas (compared with urban), and those in states with more direct care worker hours (per week per bed) had greater odds of high rating (OR = 1.722; P < .001 and OR = 1.018, P < .05, respectively). CONCLUSIONS AND IMPLICATIONS: Online reviews are increasingly common, including in long-term care. These reviews are a promising source of information about important aspects of satisfaction, particularly in care settings that lack a public reporting infrastructure. We found several significant associations between online ratings and community-level factors, suggesting these reviews may be a valuable source of information to consumers and policy makers.