Abraham A. Brody

Abstract

Objective: Examine the relationship between race and ethnicity and area-level social deprivation and Medicare home health care (HHC) agency quality for seriously ill older adults receiving HHC. Methods: A linear probability fixed effects model analyzed the association between patient-level predictors and HHC agency quality (star-rating), controlling for neighborhood level fixed effects. Linear mixed regression modeled the relationship between area-level social deprivation and receiving care from a high-quality HHC agency. An interaction term between race and social deprivation index quartiles examined whether racial disparities in accessing high-quality HHC agencies depended on the level of neighborhood social deprivation. Results: The final sample consisted of 213 491 Medicare beneficiaries. Reduced access to high-quality HHC was associated with identifying as Black (1.2 % point lower, P

Abstract

Objectives: Home health care (HHC) plays a pivotal role in serving millions of US adults aging in place. Although the HHC population is growing rapidly in both size and diversity, driven by an aging US population and a changing demographic profile, there are increasing concerns of equity in HHC, particularly regarding how vulnerable populations are affected under current HHC practices. The purpose of this study was to examine the variations in accessing high-quality HHC in racial and ethnic minority groups and persons living with dementia. Design: Cross-sectional, secondary analysis. Setting and Participants: Older adults who received HHC in 2016 from agencies with a star rating of overall care quality from the Home Health Compare program. Methods: Start of care data from the 2016 HHC Outcome and Assessment Information Set was linked to Master Beneficiary Summary File, Home Health Compare, and Provider of Services file to address the aim. Multinomial regressions were used in analysis when risk-adjusting for individual and agency characteristics. Results: Our risk-adjusted estimates, based on data from 574,682 older adults aged ≥65 years served by 8634 HHC agencies nationwide (2290 offering high-quality care, 4023 providing moderate-quality care, and 2321 delivering low-quality care), revealed significant disparities. Non-Hispanic Blacks (relative risk ratio, 0.62; 95% CI, 0.61–0.64) and Hispanics (relative risk ratio, 0.72; 95% CI, 0.70–0.74) were significantly less likely to receive care from high-quality agencies. Additionally, having dementia exacerbated disparities in accessing high-quality HHC between racial and ethnic minorities and white Americans. Conclusions and Implications: Racial and ethnic minority individuals face significant disadvantages in accessing high-quality HHC, with persons living with dementia from these groups being the most disadvantaged. Further research is warranted to investigate the referral and admission processes for HHC. Our findings highlight the need for actions from clinicians and policymakers to tackle potential biases in the aforementioned care processes.

Abstract

Home health care (HHC) plays a pivotal role in serving millions of US adults aging in place. Although the HHC population is growing rapidly in both size and diversity, driven by an aging US population and a changing demographic profile, there are increasing concerns of equity in HHC, particularly regarding how vulnerable populations are affected under current HHC practices. The purpose of this study was to examine the variations in accessing high-quality HHC in racial and ethnic minority groups and persons living with dementia.

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In the United States, nearly 1 million older adults reside in assisted living facilities, which aim to provide support for safe, autonomous living. However, low-income residents, especially those in Medicaid-supported facilities, experience unmet medical and social complex care needs and limited serious illness communication due to limited resources. The objective of this study was to explore the complex care needs and serious illness communication challenges experienced by low-income older adults in Medicaid-supported assisted living. A qualitative secondary framework analysis was conducted on data from a parent qualitative study involving 17 residents aged 60 and older with serious illnesses at a Medicaid-supported facility in New York City. Residents completed the Edmonton Symptom Assessment Scale and participated in semistructured interviews. This study was guided by the National Consensus Project for Quality Palliative Care, focusing on the residents' experiences, complex care needs, and communication within palliative care domains. Residents were predominantly Black and Hispanic, with nearly one-third having a history of homelessness or shelter use, and they experienced a high symptom burden. Four key themes emerged: (1) compromised quality of life; (2) high symptom burden and limited access to care, with residents reporting pain, fatigue, and emotional distress; (3) communication gaps while navigating health care, resulting in frustration and feelings of being unheard; and (4) fragmented care coordination, which exacerbated feelings of isolation and mistrust in the health care system. The findings reveal that Medicaid-supported assisted living residents encounter substantial challenges related to complex care needs and serious illness communication. There is an urgent need for community-based interventions to enhance care access, improve symptom management, and facilitate effective communication, ultimately supporting the residents' quality of life and health outcomes. Enhanced training for staff and policy changes are key to addressing these systemic barriers to care.

Abstract

We sought to identify patterns in occupational therapy (OT) and physical therapy (PT) home health care visits among people living with dementia (PLWD) by (1) level of function care partner report compared with administrative data, (2) race and ethnicity, and (3) level of socioeconomic resources.

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BACKGROUND: Despite the need, care partners of persons living with mild cognitive impairment (MCI) use supportive services less. The unique needs of care partners to persons living with MCI are not well described. This study explores how care partners support the inner strength of persons newly diagnosed with MCI. METHODS: Nine dyads of persons living with MCI and their care partners completed semi-structured interviews, analyzed according to the Listening Guide methodology. RESULTS: Care partners described supporting inner strengths of persons living with MCI by carrying the cognitive load and being reliable. Reconceptualizing identity was foundational. Across themes, care partners needed simultaneous support for themselves. DISCUSSION: This study represents the perspectives of a well-defined group of care partners to persons living with MCI. Eliciting the perspectives of underrepresented care partners and equitable access to MCI diagnosis are essential for future research. Dyadic supportive services tailored for MCI using a strengths-based approach are needed. Highlights: Care partners to persons living with mild cognitive impairment (MCI) are unique. Care partners support inner strength of persons living with MCI and need simultaneous support. Care partners reconceptualize their identities, are reliable, and carry cognitive load. Methods for eliciting perspectives of underrepresented care partners are needed. Supportive services tailored for MCI using a strengths-based approach are needed.

Abstract

Background: In the United States, nearly 1 million older adults reside in assisted living facilities, which aim to provide support for safe, autonomous living. However, low-income residents, especially those in Medicaid-supported facilities, experience unmet medical and social complex care needs and limited serious illness communication due to limited resources. Objective: The objective of this study was to explore the complex care needs and serious illness communication challenges experienced by low-income older adults in Medicaid-supported assisted living. Methods: A qualitative secondary framework analysis was conducted on data from a parent qualitative study involving 17 residents aged 60 and older with serious illnesses at a Medicaid-supported facility in New York City. Residents completed the Edmonton Symptom Assessment Scale and participated in semistructured interviews. This study was guided by the National Consensus Project for Quality Palliative Care, focusing on the residents’ experiences, complex care needs, and communication within palliative care domains. Results: Residents were predominantly Black and Hispanic, with nearly one-third having a history of homelessness or shelter use, and they experienced a high symptom burden. Four key themes emerged: (1) compromised quality of life; (2) high symptom burden and limited access to care, with residents reporting pain, fatigue, and emotional distress; (3) communication gaps while navigating health care, resulting in frustration and feelings of being unheard; and (4) fragmented care coordination, which exacerbated feelings of isolation and mistrust in the health care system. Conclusion: The findings reveal that Medicaid-supported assisted living residents encounter substantial challenges related to complex care needs and serious illness communication. There is an urgent need for community-based interventions to enhance care access, improve symptom management, and facilitate effective communication, ultimately supporting the residents’ quality of life and health outcomes. Enhanced training for staff and policy changes are key to addressing these systemic barriers to care.

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