Explore the vast range of titles available.

The COVID-19 pandemic has amplified the role of telehealth in health care delivery. Regional variation in internet access and telehealth use are well-documented, but the effect of neighborhood factors, including the pervasiveness of broadband internet, on older adults' telehealth usage in the context of internet access is not known. This study aimed to investigate how individual and neighborhood characteristics, including the pervasiveness of neighborhood broadband internet subscription, are associated with engagement in telehealth among older adults with internet access. In this cross-sectional study, we included 5117 community-living older adults aged ≥65 years, who participated in the 2017 National Health and Aging Trends Study with census tract-level data for participants' places of residence from the American Community Survey. Of an estimated 35.3 million community-living older adults, 21.1 million (59.7%) were internet users, and of this group, more than one-third (35.8%) engaged in telehealth. In a multivariable regression model adjusted for individual- and neighborhood-level factors, age, education, income, and the pervasiveness of neighborhood broadband internet subscription were associated with engagement in telehealth, while race, health, county metropolitan status, and neighborhood social deprivation were not. Among internet users, living in a neighborhood at the lowest (versus highest) tertile of broadband internet subscription was associated with being 40% less likely to engage in telehealth (adjusted odds ratio 0.61, 95% CI 0.42-0.87), all else equal. Neighborhood broadband internet stands out as a mutable characteristic that is consequential to engagement in telehealth.

Most Persons with Dementia (PwD) in the U.S. live in the community, relying on family/unpaid caregiving networks to meet their care needs. Caregiving network precarity refers to insecurity or instability in these networks, defined as caregiver(s) being unable or unwilling to continue in their role. While emerging evidence suggests that these networks are dynamic (i.e., members and roles change over time), little is currently known regarding factors associated with network precarity. This information is particularly relevant in the case of \"dually-enrolled\" PwD: individuals who qualify for Medicaid insurance due to limited financial resources and who have greater social vulnerabilities and experience higher rates of adverse outcomes. Using longitudinal 2021-2022 linked health plan, Medicaid claims, and clinical assessment data for a diverse sample of community-living, dually-enrolled PwD (n = 2,841), we identify factors associated with caregiver reports of being unable or unwilling to continue providing care. We estimated adjusted odds of incident network precarity using multivariable Generalized Linear Models with a logit link, binomial family, and an exposure term to account for time under observation. PwD in our sample had a mean age of 83.8 years (SD=8.4), 78.0% were female, 28.4% were Non-Hispanic White, 32.4% were Hispanic, 18.7% were Non-Hispanic Black, and 12.8% were Asian. In adjusted models, declines in health status were strongly associated with caregiver(s) reporting being unable/unwilling to continue providing care. PwD were more likely to experience incident caregiving network precarity if the PwD had recently experienced an increase in cognitive impairment (aOR: 2.98; 95% CI: 1.97-4.51), functional impairment (aOR: 1.71; 95% CI: 1.07-2.74), or bowel incontinence frequency (aOR: 2.33; 95% CI: 1.38-3.93), or began resisting care (aOR: 2.47; 95% CI: 1.69-3.61). Findings highlight the importance of identifying and addressing shifts in health and functional status for PwD and offering targeted supports to caregivers during these key inflection points. Better supporting dementia caregivers, particularly as they are faced with increasing or changing demands related to their caregiving role, is a critical component to facilitating stable and effective dementia care for community-living PwD.

Background Medicaid home and community-based services (HCBS) provide services such as personal care, nursing, and home-delivered meals to aging adults and individuals with disabilities. HCBS are available to people across racial and ethnic groups, yet racial disparities in Medicaid HCBS utilization and expenditures have been understudied. Individuals with multiple sclerosis (MS) may be particularly impacted by HCBS, as nearly one-third requires assistance at home. The present study examined whether disparities exist in Medicaid HCBS utilization and expenditures among HCBS users with MS. Methods We used secondary data to conduct a retrospective cohort analyses including 7550 HCBS recipients with MS. Demographic data was obtained from the Medicaid Analytic eXtract Personal Summary file, Medicaid HCBS service utilization and expenditures were obtained from the Other Therapy file, and comorbidities from the Medicare Chronic Condition Warehouse. Univariate and bivariate statistics were used to describe the sample and provide comparisons of characteristic by race. Logistic regression predicted the likelihood of using HCBS type and gamma regression was used to predict Medicaid HCBS expenditures. Results Black HCBS users were younger, more likely to be female, and were more impaired than Whites. Multivariate analyses showed that Blacks were less likely to receive case management, equipment, technology and modification services, and nursing services compared to Whites. Additionally, Black men had the lowest Medicaid HCBS expenditures, while White men had the highest. Conclusions Findings shed light on disparities among HCBS users with MS. As Blacks are already disproportionately affected by MS, these results reveal target areas for future research. Future work should examine the factors that contribute to these disparities, as well as determine the extent to which these inequities impact outcomes such as hospitalizations and nursing home admissions.

This review aims to investigate the link between narrative identity, generativity, and storytelling in African American elders. Storytelling has been a method of intergenerational communication and connection for a number of years in the African American community. Storytelling has also strengthened generative ties and intergenerational relationships. Erikson's eight stages of psychological development are used to examine narrative identity and generativity. Research exploring the life experiences of African American elders is also presented. This article examines the current research on narrative identity and generativity and the African American experience, and makes suggestions for future endeavors in the field. It is recommended that future research consider the three—narrative identity, generativity, and storytelling—to better understand the experience of older African Americans.

Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain. To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death. This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020. The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records. The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents. Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.

Background More than 4 million older adults in the United States use publicly funded home-and community-based services (HCBS) which were disrupted during the COVID-19 pandemic. There is paucity of empirical evidence of how service disruptions influenced consumer needs in different types of HCBS. Therefore, we evaluate changes in service use and consumer-reported unmet service needs in HCBS during the COVID-19 pandemic (2021–2022) versus pre-pandemic (2018–2019), to inform future public health emergency (PHE) preparedness. Methods We analyzed repeated cross-sectional survey data from the National Core Indicators- Aging and Disability Adult Consumer Survey in two survey waves, 2018–2019 and 2021–2022. We included community-dwelling, older HCBS consumers (age ≥ 65 years; n  = 7143) from 11 states that participated in both survey waves. We measured service use and consumer-reported unmet needs as outcomes for six commonly used HCBS including personal care, homemaker, meal delivery, adult day, transportation, and caregiver respite/support. Using logistic regression, we calculated adjusted odds ratios (aOR) and 95% confidence interval (CI) to evaluate changes in outcomes during versus pre-pandemic, adjusting for demographics, health-related variables, and self- versus proxy-response, with random intercepts for each state. Results Compared to 2018–2019, during 2021–2022, odds of service use increased for personal care (aOR, 1.24; 95% CI, 1.09, 1.40) and caregiver respite/support (aOR, 1.28; 95% CI, 1.00, 1.63) but decreased for homemaker services (OR, 0.69; 95% CI, 0.60, 0.79) and meal delivery (aOR, 0.81; 95% CI, 0.70, 0.93). During the PHE, odds of unmet service needs increased for personal care (aOR, 1.23; 95% CI, 1.03, 1.46) and meal delivery (aOR, 1.26; 95% CI, 1.01, 1.56), and decreased for caregiver respite/support (aOR, 0.49; 95% CI, 0.35, 0.70). Conclusions During the PHE, simultaneous increase in services use and unmet service needs for some HCBS (e.g. personal care) suggests that temporary PHE measures taken were insufficient to offset the demand for those services. For caregiver respite/support, increased service use and decreased unmet service needs suggests that the temporary PHE measures for caregiver support may have offset a rise in service demand. These findings can inform evaluations of temporary PHE policies for HCBS and disaster preparedness efforts for future PHEs. Clinical trial number Not applicable.

Addressing disparities related to Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) is a priority for policymakers, practitioners, and researchers. In this perspective, we highlight important gaps and opportunities presented during Session 4: Disparities in Health Care Access, Utilization, and Quality, of the 2023 National Research Summit on Care, Services, and Supports for Persons Living with Dementia and Their Care Partners/Caregivers. We call attention to three areas: (1) increased data availability and linkages across local, state, and federal levels; (2) health information technology use and related care access, quality, and costs; and (3) diverse health insurance models used to enable access to medical care, long‐term services and supports, and address care quality. Recommendations present considerations for future research and opportunities to strengthen policies related to the care of persons living with AD/ADRD. Highlights Disparities related to AD/ADRD negatively impact diverse populations. Limited data on underrepresented groups make it difficult to assess the full scope of disparities. Increasing access to health information technology is necessary for reducing disparities. More information is needed to understand the impact of payment models on addressing disparities.

As the locus of long-term care in the United States shifts from institutions to the community, paid caregivers (i.e., home health aides, personal care attendants) are providing more hands-on care to persons with dementia living at home. Yet, little is known about how family caregivers engage with paid caregivers. We conducted in-depth, semi-structured interviews (n = 15) with family caregivers, of persons living at home with severe dementia, and enriched our findings with data from a second cohort of family caregivers of persons with dementia (n = 9). Whether paid caregivers were hired privately or employed via a Medicaid-funded agency, family caregivers reported that they needed to manage paid caregivers in the home. Core management tasks were day-to-day monitoring and relationship building with family caregivers; training paid caregivers and coordinating care with homecare agencies was also described. In order to support family caregivers of individuals with dementia at home, it is important consider their preferences and skills in order to effectively manage paid caregivers. Support of efforts to build a high-quality paid caregiving workforce has the potential to improve not only care delivered to persons with dementia, but the experiences of their family caregivers.

Policy Points Little attention to date has been directed at examining how the long‐term services and supports (LTSS) environmental context affects the health and well‐being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person‐reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state‐level LTSS‐relevant environmental characteristics stand to improve the health and well‐being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions. Context Long‐term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person‐reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them. Methods We advance a conceptual framework of LTSS‐relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person‐reported care experiences with public use spatial data. We assess relationships between LTSS‐relevant environmental characteristic domains and person‐reported care adverse consequences due to unmet need, participation restrictions, and subjective well‐being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status. Findings We find the LTSS environment is highly associated with person‐reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community‐Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well‐being. Observed relationships between measures of LTSS‐relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations. Conclusions We present a framework and analyses describing the variable relationships between LTSS‐relevant environmental factors and person‐reported care experiences. LTSS‐relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state‐ and community‐based policies and practices that support aging in place.

Medicare conditions of participation require hospitals to provide training to family and unpaid caregivers when their support is necessary to enact the postdischarge care plan. However, caregivers often report feeling unprepared for this role. To describe the characteristics of caregivers who assist with posthospitalization care transitions and assess the prevalence of and factors associated with receipt of adequate transitional care training. This cross-sectional study analyzed data from the 2017 National Health and Aging Trends Study and its linked National Study of Caregiving, surveys of Medicare beneficiaries and their family and unpaid caregivers. The present study included family caregivers for community-living Medicare beneficiaries 65 years or older with disabilities. Data analysis was performed from June to September 2020. Characteristics of family caregivers by whether they assisted during a posthospitalization care transition in the year preceding the survey interview. Unweighted frequencies and weighted percentages, as well as the results of weighted Pearson and Wald tests for differences between groups, are reported. Receipt of the training needed to manage the older adult's posthospitalization care transition (hereafter referred to as adequate transitional care training) as a function of individual caregiver characteristics was modeled using multivariable, weighted logistic regression. Of 1905 family caregivers, 618 (58.9%) were 60 years or older, 1288 (63.8%) were female, and 796 (41.7%) assisted with a posthospitalization care transition. Those who assisted with a posthospitalization care transition were more likely to report experiencing financial (154 [18.3%] vs 123 [10.1%]; P < .001), emotional (344 [41.3%] vs 342 [31.1%]; P < .001), and physical (200 [22.2%] vs 170 [14.6%]; P = .001) difficulty associated with caregiving. Among caregivers who assisted during a posthospitalization care transition, 490 (59.1%) reported receiving adequate transitional care training. Caregivers were less likely to report receiving adequate training if they assisted an older adult who was female (316 [62.3%] vs 227 [73.2%]; P = .02), Black (163 [14.0%] vs 121 [19.8%]; P = .02), or enrolled in Medicaid (127 [21.2%] vs 90 [31.9%]; P = .01). After adjusting for older adult characteristics, caregivers were half as likely to report receiving adequate training if they were Black (adjusted odds ratio [aOR], 0.52; 95% CI, 0.31-0.89) or experienced financial difficulty (aOR, 0.50; 95% CI, 0.31-0.81). Caregivers were more than twice as likely to report receiving adequate training if they were female (aOR, 2.44; 95% CI, 1.65-3.61) or spoke with the older adult's clinician about his or her care in the past year sometimes or often vs never (aOR, 1.93; 95% CI, 1.19-3.12). In this cross-sectional study, caregivers were less likely to receive adequate transitional care training if they were Black; experienced financial difficulty; or cared for a Black, female, or Medicaid-enrolled older adult. These findings suggest that changes to the discharge process, such as using standardized caregiver assessments, may be necessary to ensure equitable support of family caregivers.