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\u27s 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\u27s 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

A National Typology of Health Service Regulation in Assisted Living

Background and Objectives State regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents’ outcomes across similarly regulated communities. Research Design and Methods We used qualitative and quantitative methods to empirically develop and describe a typology of state AL regulations that captures inter and intra-state variation. Based on the rules governing health services, we created regulatory specificity scores for five thematic dimensions: medication administration, third-party care, skilled nursing, medication review, and licensed nurse staffing. With these scores, we conducted a K-means cluster analysis to identify groups of AL license types. To differentiate the regulatory types, we calculated standardized mean differences across structure, process, outcome, and resident characteristics of the AL communities licensed under each type. Results We identified six types of AL differentiated by the regulatory provisions governing health services: Housing, Holistic, Hybrid, Hospitality, Healthcare, and Health Support. The types align with previous work and reflect tangible differences in resident characteristics, health service structures, processes, and outcomes. Discussion and Implications This typology effectively captures differences across regulated dimensions and can inform and support quality of care. Researchers, policymakers, and consumers may benefit from using this typology and acknowledging these differences in AL licensure when designing research studies, developing policies, and selecting an AL community

Policy and Methods in Health Services Research

This dissertation consists of two policy papers and one methods paper, all grounded in applied, empirical health-services research. The first two papers concern the influence of medical underwriting in the market for long-term care insurance in the U.S. The third presents a framework for evaluating provider preference as an instrumental variable in comparative effectiveness research with multiple treatments, using as an empirical demonstration a study comparing the safety of five atypical antipsychotics and their effects on chronic disease incidence. In the first paper, I estimate an empirical model of the factors on which firms make decisions to underwrite individuals for long-term care insurance, using data on the health and coverage decisions for applicants at two U.S. firms. I apply the model parameters to a population-based sample to determine what proportion of households of prime ages to purchase long-term care insurance would be able to qualify for policies if they were to apply for coverage. Among the general population, I estimate that 40 percent of individuals would have their applications rejected if they were to apply for long-term care insurance---a rejection rate substantially higher than the rejection rate of 20--25 percent of applicants in the actual market. The second paper examines policy ramifications of the bounds on coverage in the individual market for long-term care insurance that I establish in paper one. I study two types of policies designed to encourage individuals to purchase long-term care insurance, tax incentives and state Partnership programs, estimating how the effects of differ with respect to individuals' underwriting probabilities. I exploit variation in the timing of states' implementation of these policies with difference-in-difference models, and estimate the demand elasticity of long-term care premiums using simulated statewide marginal tax prices as in instrumental variable for individual prices. I find that the response to these policy incentives is highly dependent on individuals' underwriting probabilities: conditional on wealth and income, tax and Partnership have no apparent effect on insurance purchase among low-approval households, and program effect appears to be concentrated among healthier individuals with high approval probabilities. In evaluating reforms for long-term care financing and their potential to increase private insurance rates, as well as reduce financial pressure on public safety-net programs, policy makers need to consider the role of underwriting in the market for long-term care insurance. The third paper proposes a framework for assessing provider preference as instrumental variables in comparative effectiveness research and describes diagnostic tools to validate (or debunk) a candidate instrument. In an applied analysis, I show how to use these tools to compare multiple treatments. I compare the safety of commonly prescribed atypical antipsychotics using physician prescribing preference as an instrumental variable. Widespread adoption of a basic protocol and road map for validating potential instruments, particularly the use of sensitivity tests and compliers analysis, would improve the quality of comparative effectiveness research.Health Polic

Developments in the Market for Assisted Living: Residential Care Availability in 2017

Objectives Describe how the availability of assisted living (AL) and dementia-specific AL vary across counties and correlate with demographic and socioeconomic characteristics. Design Maps, univariate statistics, and standardized mean differences show the differences between counties with high and low levels of AL market penetration, and between counties with and without dementia-specific AL. Setting and Participants Data collected from state agencies on licensed AL communities, capacity, and geographic location, and population characteristics from the Area Health Resource file. We include novel and previously undescribed data on dementia-specific AL licenses in 21 states. Measures AL market penetration is reported as the number of AL units or beds per 1000 persons over age 65 years in a county. Results In comparison to counties with the lowest AL penetration, high-penetration counties had higher high school and college education attainment (mean 25.3% vs 18.5%) and median annual income ($56,000 vs$46,800), and lower poverty (12.8% vs 17.3%) and unemployment rates (3.9% vs 5.1%). Compared to counties with AL but no dementia-specific care, counties with dementia care had substantially higher college attainment (24.6% vs 17.7%) and had higher urbanity index (3.8 vs 5.6 on a 1-9 scale, 1 most urban). Counties with dementia care also had, on average, 16% more in median household income ($54,200 vs$46,400) and 40% greater home value ($159,800 vs.$113,600). Conclusions and Implications Large socioeconomic disparities persist among counties without any AL or low penetration of AL in their borders in comparison to those with high AL penetration, as well as between counties with and without dementia-specific AL communities. There may be a mismatch in need and availability of residential care options for older adults with Alzheimer\u27s disease and related dementias that contributes to the disproportionate share of racial/ethnic minorities with dementia in nursing homes. Lack of available AL beds in the communities where Medicaid individuals reside could make rebalancing efforts doubly difficult, in that Medicaid enrollees may be reluctant to move out of their neighborhoods

Trends in Serious Mental Illness in US Assisted Living Compared to Nursing Homes and the Community: 2007-2017

Objective Little is known about the prevalence of serious mental illness (SMI) in assisted living (AL) communities in the United States. Trends in the prevalence of SMI in AL communities were examined over time and in relationship to characteristics such as dual eligibility and health conditions. Within- and between-state variability of SMI in AL was also examined. Design Samples of Medicare beneficiaries who lived in the 48 contiguous states were created: individuals who resided in the community, in a nursing home (NH), and in an AL community on December 31st of each year (2007–2017). We conducted univariate analysis to display the trends in SMI over time in AL compared with NHs and the community. To demonstrate intrastate variability, we examined the prevalence of SMI for each state. We described within-nation and within-state variability using a Lorenz curve and GINI coefficients, respectively. Results The prevalence of SMI in AL increased by 54%, rising from 7.4% in 2007 to 11.4% in 2017. Residents with SMI were more likely to be dually eligible for Medicare and Medicaid than residents without SMI. The prevalence of SMI in AL ranged from to 3.2% in Wyoming to 33.1% in New York. Approximately 10% of AL communities had over half of the sample\u27s AL residents with SMI. Conclusion Given the increased proportion of residents with SMI in AL, research is needed into the mental health and social care needs of this population. Analysis is needed to uncover reasons for variations among states

Excess Mortality Among Assisted Living Residents with Dementia During the COVID-19 Pandemic

Objective: To evaluate whether assisted living (AL) residents with Alzheimer\u27s disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. Design: Retrospective cohort study. Setting and participants: Two cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit zip codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020. Method: By linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects. Results: Of the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL. Conclusions and implications: AL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia

The Relationship Between States\u27 Staffing Regulations and Hospitalizations of Assisted Living Residents

Assisted living provides housing and long-term care services to more than 811,000 older adults in the United States daily and is regulated by the states. This article describes changes in the specificity of state regulations governing the staffing in assisted living settings (that is, requirements for sufficient staffing or staffing ratios or levels) between 2007 and 2018 and the association between these changes and rates of hospitalization among a national sample of assisted living residents, including a subgroup with dementia. We found that increased regulatory specificity for direct care workers (for example, a change from requiring sufficient direct care worker staffing to requiring a specific staffing ratio or level) was associated with a 4 percent reduction in the monthly risk for hospitalization among residents in our sample and a 6 percent reduction among the subgroup with dementia. However, an increase in regulatory specificity for licensed practical nurses was associated with a 2.5 percent increase in the monthly risk for hospitalization and a 5 percent increase among the subgroup with dementia. Given that no federal requirements exist for the number of staff members or composition of staff in assisted living, these findings can inform states\u27 policy decisions about staffing requirements for assisted living settings

Memory Care Reduces Nursing Home Admissions Among Assisted-Living Residents with Dementia

Introduction We compare nursing-home and hospital admissions among residents with Alzheimer\u27s disease and related dementias (ADRD) in memory-care assisted living to those in general assisted living. Methods Retrospective study of Medicare beneficiaries with ADRD in large (\u3e25 bed) assisted-living communities. We compared admission to a hospital, to a nursing home, and long-term (\u3e90 day) admission to a nursing home between the two groups, using risk differences and survival analysis. Results Residents in memory-care assisted living had a lower adjusted risk of hospitalization (risk difference = −1.8 percentage points [P = .014], hazard ratio = 0.93 [0.87–1.00]), a lower risk of nursing-home admission (risk difference = −2.2 percentage points [P \u3c .001], hazard ratio = 0.87 [−.79–0.95]), and a lower risk of a long-term nursing home admission (risk difference = −1.1 percentage points [P \u3c .001], hazard ratio = 0.71 [0.57–0.88]). Discussion Memory care is associated with reduced rates of nursing-home placement, particularly long-term stays, compared to general assisted living

Table1_Adaptation of a social risk screening and referral initiative across clinical populations, settings, and contexts in the Department of Veterans Affairs Health System.docx

Identifying and addressing social risks and social needs in healthcare settings is an important step towards achieving health equity. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that aims to systematically identify and address social needs. Since initial piloting in 2018, our team has collaborated with clinical and operations partners to implement ACORN across multiple VA clinical settings while adapting and tailoring the initiative to meet the needs of different populations, specialties, and individuals administering screening. Given ACORN's complexity as a growing initiative with multiple partners and frequent real-time modifications within a large national healthcare system, we recognized a need to systematically document the rationale and process of adaptations over time. We looked to three implementation frameworks—RE-AIM, the Adaptome, and FRAME—to describe the rationale for adaptations, the nature of and context within which adaptations were made, and the details of each adaptation. In this manuscript, we uniquely interweave these three frameworks to document adaptations to ACORN across diverse VA clinical settings, with a focus on how adaptations support the promotion of heath equity in the Veteran population.</p