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Background: Novel hospital diversion strategies are needed to support a growing number of patients with dementia living in the community. One promising model is community paramedicine (CP), which deploys paramedics to the home, who consult with a physician to coordinate treatment and assess disposition. While evidence suggests CP can manage many patients without escalation to the emergency department (ED), no studies have evaluated optimal CP utilization for patients with dementia. Therefore, we compare the use and outcomes of CP for homebound patients with and without dementia. Methods: This retrospective cohort study examines 251 homebound patients receiving home‐based primary care, who utilized a physician‐led CP service between March 2017 and May 2022. Linked electronic health record data included patient demographics, clinical characteristics, and CP encounter details. Dementia status and CP outcomes, including rates of ED transport, over‐transport (i.e., transported, but not hospitalized), and under‐transport (i.e., not transported, but ED visit within 3 days), were determined via chart review. Using logistic regression, we modeled the association of dementia status with over‐ and under‐transport, adjusting for age, sex, and chief complaint. Results: Fifty‐three percent of CP patients had dementia. Their most common chief complaints were dyspnea (24.3%), altered mental status (17.9%), and generalized weakness (9.8%). We found no significant difference in ED transport rates by dementia status (25.4 vs. 22.8%, p = 0.54). Dementia diagnosis was associated with lower rates of over‐transport (OR = 0.21, p = 0.03, CI [0.05, 0.85]) and comparable rates of under‐transport (OR = 0.70, p = 0.47, CI [0.27, 1.83]) in adjusted models. Conclusions: CP has effectively managed a diverse population of homebound patients with dementia cared for via home‐based primary care. Future work should examine potential cost savings and use of CP in dementia care across geographic and healthcare settings. See related article by Kim et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Given the significant exposures experienced by the World Trade Center (WTC) general responders, there is increasing interest in understanding the effect of these exposures on aging in this population. We aim to identify factors that may be associated with frailty, a clinical syndrome characterized by a decrease in one's reserve that has been linked to poor health outcomes. Methods: WTC general responders enrolled in the WTC Health Program aged 50 and older provided informed consent. Validated frailty assessments, the Frailty Phenotype (with the Johns Hopkins Frailty Assessment Calculator) along with the FRAIL scale, categorized nonfrail from prefrail/frail. Fall risk, functional status, and cognition were also assessed. WTC variables, including an identified WTC‐certified condition, were utilized. The risk of frailty was estimated using log binomial regression analysis. A 95% confidence interval (CI) was used to estimate the prevalence ratio (PR). Results: One hundred and six participants were included; 38 (35.8%) were classified as pre‐frail or frail. More of the pre‐frail/frail group were obese (57.9% vs. 25%; p = 0.004) and had a WTC‐certified condition (78.9% vs. 58.8%; p = 0.036). Obesity (PR = 2.43, 95% CI = 1.31, 4.53), a WTC‐certified condition (PR = 1.77, 95% CI = 1.09, 2.89), and risk of falling (PR = 1.97, 95% CI = 1.01, 3.84) were independently associated with frailty. Conclusions: Obesity and having a WTC‐certified condition were found to be risk factors for frailty in our pilot study. Future work may focus on further identifying risk factors for frailty in the larger WTC general responder population. [ABSTRACT FROM AUTHOR]

The article presents a study which examined changes in social isolation in older adults using nationally representative cohort data to elucidate potential differences in demographic characteristics between chronic, intermittent, and no social isolation. Topics include baseline demographic characteristics across social isolation persistence groups, factors associated with persistent social isolation, and importance of characterizing social isolation as a chronic circumstance for certain groups.

Background: Families play a critical role in end‐of‐life (EOL) care for nursing home (NH) residents with dementia. Despite the important role of family, little is known about the availability and characteristics of families of persons with dementia who die in NHs. Methods: This is a retrospective cohort study of 18,339 individuals 65 years and older with dementia who died in a Utah NH between 1998 and 2016, linked to their first‐degree family (FDF) members (n = 52,566; spouses = 11.3%; children = 58.3%; siblings = 30.3%). Descriptive statistics, chi‐square tests, and t‐tests were used to describe the study cohort and their FDF members and to compare sociodemographic and death characteristics of NH decedents with (n = 14,398; 78.5%) and without FDF (n = 3941; 21.5%). Results: Compared with NH decedents with FDF, NH decedents with dementia without FDF members were more likely to be older (mean age 86.5 vs 85.5), female (70.5% vs 59.3%), non‐White/Hispanic (9.9% vs 3.2%), divorced/separated/widowed (84.4% vs 61.1%), less educated (<12th grade; 42.2% vs 33.7%), have Medicare and Medicaid (20.8% vs 12.5%), and die in a rural/frontier NH (25.0% vs 23.4%). NH decedents who did not have FDF were also more likely to die from cancer (4.2% vs 3.9%), chronic obstructive pulmonary disease (COPD; 3.9% vs 2.5%), and dementia (40.5% vs 38.4%) and were less likely to have 2+ inpatient hospitalizations at EOL (13.9% vs 16.2%), compared with NH decedents with FDF. Conclusions: Findings highlight differences in social determinants of health (e.g., sex, race, marital status, education, insurance, rurality) between NH decedents with dementia who do and do not have FDF—factors that may influence equity in EOL care. Understanding the role of family availability and familial characteristics on EOL care outcomes for NH residents with dementia is an important next step to informing NH dementia care interventions and health policies. [ABSTRACT FROM AUTHOR]

INTRODUCTION: There is evidence that health care utilization increases after incident dementia, particularly after dementia diagnosis and toward the end of life; however, less is known about utilization in the years before dementia identification. METHODS: In this retrospective cohort study we obtained data on n = 5547 beneficiaries from the Health and Retirement Study (HRS)‐Medicare linked sample (n = 1241 with and n = 4306 without dementia) to compare longitudinal trends in health care costs and utilization in the 6 years preceding dementia identification relative to a confounder‐balanced reference group without dementia. RESULTS: We found that persons with dementia had a greater prevalence of outpatient emergency department (ED), inpatient hospital, skilled nursing, and home health use, and total health care costs in the years preceding dementia identification compared to their similar counterparts without dementia across a comparable timespan in later life. CONCLUSIONS: This study provides evidence to suggest greater healthcare burden may exist well before clinical manifestation and identification of dementia. Highlights: Several studies have documented the tremendous healthcare‐related costs of living with dementia, particularly toward the end of life.Dementia is a progressive neurodegenerative disease, which, for some, includes a prolonged pre‐clinical phase. However, health services research to date has seldom considered the time before incident dementia.This study documents that health care utilization and costs are significantly elevated in the years before incident dementia relative to a demographically‐similar comparison group without dementia. [ABSTRACT FROM AUTHOR]

Background: We aimed to describe the roles and challenges of family caregivers involved in patients' cancer treatment decision‐making. Methods: Family caregiver‐reported data were analyzed from a national survey conducted in the United States by CancerCare® (2/2021–7/2021). Four select‐all‐that‐apply caregiver roles were explored: (1) observer (patient as primary decision‐maker); (2) primary decision‐maker; (3) shared decision‐maker with patient and (4) decision delegated to healthcare team. Roles were compared across five treatment decisions: where to get treatment, the treatment plan, second opinions, beginning treatment and stopping treatment. Ten challenges faced by caregivers (e.g., information, cost, treatment understanding) were then examined. χ2 and regression analyses were used to assess associations between roles, decision areas, challenges and caregiver sociodemographics. Results: Of 2703 caregiver respondents, 87.6% reported involvement in patient decisions about cancer treatment, including 1661 who responded to a subsection further detailing their roles and challenges with specific treatment decisions. Amongst these 1661 caregivers, 22.2% reported an observing role, 21.3% a primary decision‐making role, 53.9% a shared decision‐making role and 18.1% a role delegating decisions to the healthcare team. Most caregivers (60.4%) faced ≥1 challenge, the most frequent being not knowing how treatments would affect the patient's physical condition (24.8%) and quality of life (23.2%). In multivariable models, being Hispanic/Latino/a was the strongest predictor of facing at least one challenge (b = −0.581, Wald = 10.69, p <.01). Conclusions: Most caregivers were involved in patients' cancer treatment decisions. The major challenge was not understanding how treatments would impact patients' physical health and quality of life. Challenges may be more commonly faced by Hispanic/Latino/a caregivers. Patient or Public Contribution: The CancerCare® survey was developed in partnership with caregiving services and research experts to describe the role of cancer family caregivers in patient decision‐making and assess their needs for support. All survey items were reviewed by a CancerCare advisory board that included five professional patient advocates and piloted by a CancerCare social worker and other staff who provide counselling to cancer caregivers. [ABSTRACT FROM AUTHOR]

Background: As federal and state policies rebalance long‐term care from institutional settings to home‐ and community‐based settings, reliance on formal (paid) and family (unpaid) caregivers for support at home nationally has increased in recent years. Yet, it is unknown if use of formal and family care varies by rurality. Methods: Using the Health and Retirement Study, we describe patterns in receipt of combinations of formal and family home care and self‐reported expectation of nursing home use by rurality among community‐dwelling adults aged 65+ with functional limitations from 2004 to 2016. Results: Older adults residing in rural areas are more likely to receive any family care than those in urban areas. From 2004 to 2016, a higher proportion of older adults in rural areas receive care from family caregivers exclusively while a lower proportion receive care from formal caregivers exclusively. When examining older adults in urban areas, we find the opposite — a higher proportion of urban adults rely exclusively on formal care and a lower proportion rely exclusively on family care in 2016 compared to 2004. Conclusion: We find that national estimates of sources of caregiving and their changes over time mask significant heterogeneity in uptake by rurality. Understanding how older adults in rural areas are, or are not, receiving home‐based care compared to their urban peers and how these patterns are changing over time is the first step to informing supports for family and formal caregivers. [ABSTRACT FROM AUTHOR]

Background: Adult children provide a large portion of end‐of‐life caregiving for older adults and make up the majority of caregivers for adults with dementia. Yet research has been limited to the hours of care that primary caregivers provide, neglecting the other ways adult children provide caregiving support. This study aims to describe the caregiving support adult children provide to their parents at the end of life and characterize differences by race and ethnicity and dementia status. Methods: We conducted a retrospective study using survey responses from the Health and Retirement Study between 2002 and 2018. The sample population (n = 8040) included decedents aged 65 with at least one living adult child at their time of death. Caregiving support was defined as providing financial support, providing help with basic or instrumental activities of daily living (ADLs or IADLs), or coresiding with the care recipient. Respondents were stratified by self‐identified race and ethnicity as Hispanic, non‐Hispanic White, or non‐Hispanic Black. Respondents were further stratified by dementia and marital status. Results: Black and Hispanic respondents without dementia were more likely to report receiving financial help from (28.0% and 25.9%) or coresiding with their adult children (38.9% and 49.7%) compared to White respondents (15.0% receiving financial help and 23.3% coresiding) (p < 0.05). Among respondents with dementia, 47.1% of both Black and Hispanic respondents reported coresiding with their adult children, compared to only 24.6% of White respondents (p < 0.05). Notably, married Black and Hispanic respondents reported significantly higher rates of all support types compared to married White respondents (p < 0.05). Conclusions: The majority of older adults at the end of life receive some form of care and support from their adult children, with Black and Hispanic older adults receiving particularly high rates of care and support from their adult children regardless of dementia or marital status. [ABSTRACT FROM AUTHOR]

Background: Nurse practitioners (NPs) are the largest group of providers delivering home‐based primary care (HBPC) in the U.S. We examined the association of scope‐of‐practice regulations and NP‐HBPC rates. Methods: Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state‐level analysis to examine the impact of scope‐of‐practice regulations on the utilization of NP‐HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341–99,345, 99,347–99,350) and domiciliary settings (99324–99,328, 99,334–99,337). We used linear regression to compare NP‐HBPC utilization rates between states of either restricted or reduced scope‐of‐practice laws to states with full scope‐of‐practice, adjusting for a number of NP‐HBPC providers, state ranking of total assisted living, the proportion of fee‐for‐service (FFS) Medicare beneficiaries and neighborhood‐level socio‐economic status and race and ethnicity. Results: Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope‐of‐practice, states with restricted or reduced scope‐of‐practice had higher adjusted rates of NP‐HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP‐HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full‐ scope‐of‐practice laws, respectively. The rate of NP‐HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13–1.72; p = 0.023) and reduced scope‐of‐practice laws (Beta coefficient = 0.91; 95%CI 0.03–1.79; p = 0.043) compared to states with full scope‐of‐practice laws. Conclusion: Restricted state NP scope‐of‐practice regulations were associated with higher rates of FFS Medicare NP‐HBPC care delivery compared with full or reduced scope‐of‐practice. Understanding underlying mechanisms of how scope‐of‐practice affects NP‐HBPC delivery could help to develop scope‐of‐practice regulations that improve access to HBPC for the underserved homebound population. [ABSTRACT FROM AUTHOR]

Background: Homebound status is a final common pathway for people with a variety of diseases and conditions. There are 7 million homebound older adults in the United States. Despite concerns regarding their high healthcare costs and utilization and limited access to care, the unique subsets within the homebound population are understudied. Better understanding of distinct homebound groups may enable more targeted and tailored approaches to care delivery. Therefore, in a nationally representative sample of homebound older adults we used latent class analysis (LCA) to examine distinct homebound subgroups based on clinical and sociodemographic characteristics. Materials and Methods: Using data from the National Health and Aging Trends Study (NHATS) 2011–2019, we identified 901 newly homebound persons (defined as never/rarely leaving home or leaving home only with assistance and/or difficulty). Sociodemographic, caregiving context, health and function, and geographic covariates were derived from NHATS via self‐report. LCA was used to identify the existence of distinct subgroups within the homebound population. Indices of model fit were compared for models testing 1–5 latent classes. Association between latent class membership and 1 year mortality was examined using a logistic regression. Results: We identified four classes of homebound individuals differentiated by their health, function, sociodemographic characteristics, and caregiving context: (i) Resource constrained (n = 264); (ii) Multimorbid/high symptom burden (n = 216); (iii) Dementia/functionally impaired (n = 307); (iv) Older/assisted living (n = 114). One year mortality was highest among the older/assisted living subgroup (32.4%) and lowest among the resource constrained (8.2%). Conclusions: This study identifies subgroups of homebound older adults characterized by distinct sociodemographic and clinical characteristics. These findings will support policymakers, payers, and providers in targeting and tailoring care to the needs of this growing population. [ABSTRACT FROM AUTHOR]

Background: Family caregivers play an increasing role in cancer treatment decision‐making. We examined bias reported by family caregivers in the support they and their patient received from their healthcare team when making these decisions, including associations with distress. Methods: Analysis of 2021 national survey data of family caregivers of patients with cancer (N = 2703). Bias experienced in decision support was assessed with the item: "Have you felt that the support you and the person with cancer have received for making cancer‐related decisions by your doctor or healthcare team has been negatively affected by any of the following?" Check‐all‐that‐apply response options included: age, race, language, education, political affiliation, body weight, insurance type or lack of insurance, income, religion, sexual orientation, and gender/sex. Chi‐square and regression analyses assessed associations between bias and caregiver distress (GAD‐2, PHQ‐2). Results: Of 2703 caregiver respondents, 47.4% (n = 1281) reported experiencing ≥1 bias(es) when receiving decision support for making cancer‐related decisions. Bias was more prevalent among younger caregivers, males, transwomen/men or gender non‐conforming caregivers, racial/ethnic minorities, and those providing care over a longer time period. The odds of having high anxiety (GAD‐2 scores ≥ 3) were 2.1 times higher for caregivers experiencing one type of bias (adjusted OR, 2.1; 95% CI, 1.6–2.8) and 4.2 times higher for caregivers experiencing ≥2 biases (adjusted OR, 4.2; 95% CI, 3.4–5.3) compared to none. Similar results were found for high depression scores (PHQ‐2 scores ≥ 3). Conclusions: Nearly half of caregivers involved in their care recipients' cancer‐related decisions report bias in decision support received from the healthcare team. Experiencing bias was strongly associated with high psychological distress. [ABSTRACT FROM AUTHOR]

Background: Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home‐based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited. Methods: We conducted a randomized controlled trial of HBPC versus office‐based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6‐ and 12‐months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients. Results: The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46–3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (−17.9%, 95% CI −31.0% to −1.0%; p = 0.001; number needed to treat 6, 95% CI 3–100). There were no significant differences in quality of life (1.25, 95% CI −0.39–2.89, p = 0.13), symptom burden (−1.92, 95% CI −5.22–1.37, p = 0.25) or ED visits (1.2%, 95% CI −10.5%–12.4%; p = 0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001). Conclusion: HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office‐based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination. See related Editorial by Boling et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID‐19 pandemic. The AHCaH waived the 24/7 on‐site nursing requirement and enabled hospitals to obtain full hospital‐level diagnosis‐related group (DRG) reimbursement for providing Hospital‐at‐Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. Methods: We conducted semi‐structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. Principal Findings: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre‐existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. Conclusions: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery. See related Editorial by Brody et al. in this issue. [ABSTRACT FROM AUTHOR]

Introduction: Seriously ill people with dementia living at home may be particularly vulnerable to disruptions in their care during times of crisis. The study sought to describe care experiences of those receiving home‐based primary care in New York City during the COVID‐19 pandemic and compare the experiences of people with and without dementia. Methods: We conducted a retrospective review of all electronic medical record notes between March 1, 2020 and December 30, 2020 among a sample of home‐based primary care recipients (n = 228), including all deaths that occurred in the spring of 2020. Drawing from administrative records and using an abstraction tool that included both structured (e.g., documented COVID‐19 exposure) and unstructured (e.g., text passage describing caregiver burden) data, we identified salient COVID‐19 related care experiences and identified and categorized major disruptions in care. Results: Both people with and without dementia experienced significant disruptions of paid caregiving, family caregiving, and home‐based services during the COVID‐19 pandemic. While the paid caregivers of people with dementia reported more burden to the home‐based primary care team as compared to people without dementia, we found little evidence of differences in quantity or type of COVID‐19 related disruptions relative to dementia status. Discussion: While those with dementia have distinct care needs, our findings emphasize the way that dementia may be one piece of a larger clinical picture of serious illness. In order to support all patients with high care needs in crisis, we need to understand the interdependence of clinical care, long‐term care, and family caregiving support for older adults and view dementia within the larger context of serious illness and care need. [ABSTRACT FROM AUTHOR]

The article determines whether hospital at home (HaH) is feasible or effective for socioeconomically disadvantaged patients. Topics discussed include acute length of stay, hospital readmission, and emergency department revisit. Findings suggest that HaH is feasible for low socioeconomic status (SES) patients.

Background: Adult‐children caring for a parent with cancer comprise a significant segment of caregivers. Yet less is known about adult‐child caregivers, their burden, or caregivers' and patients' gender's impact, which may differ from the well‐studied spousal caregiver. This knowledge gap may hinder efforts to ameliorate adult‐children's caregiver burden. Methods: We analyzed caregiver surveys from the Cancer Care Outcomes Research and Surveillance Consortium, a multi‐regional population‐based study of patients with colorectal or lung cancer. Using t tests and multivariate regression models, we assessed whether adult‐child and spousal caregivers' caregiving responsibilities and social/emotional and financial burdens differed and used structural equation models (SEMs) to examine mediating factors. Results: Compared with spouses/partners (N = 1007), adult‐children (N = 227) spent less time caregiving (14 vs 23 hours/week; P <.001), but experienced higher social/ emotional burden (P <.01). In models adjusted for objective caregiving burden measures and demographics, adult‐children's social/emotional (P <.05) and financial burdens (P <.01) were greater than spouses'. Poor communication quality was associated with greater social/emotional burden for both groups (P <.05). SEMs indicated that gender concordance between caregivers and patients (eg, daughters caring for mothers) and caregiver employment increased the difference between adult‐child and spouses' social/emotional burden, whereas caregiver‐patient relationship quality reduced it. Conclusions: Adult‐children spend less time caregiving than spouses/partners, but have higher social/emotional and financial caregiving burdens, partially due to adult‐children's employment, caregiver‐patients' gender concordance, and relationship quality. Gender concordance's contribution to greater social/emotional burden adds important context to prior findings, indicating female caregivers experience the most burden. Interventions that improve caregiver‐patient communication may reduce both adult‐child and spousal caregiver burden. Adult‐children spend less time caregiving than spouses/partners, but report higher social/emotional and financial caregiving burdens, partially due to adult‐children's employment and caregiver‐patients' gender makeup. Interventions to improve communication between caregivers and patients may reduce both adult‐child and spousal caregiver burden. [ABSTRACT FROM AUTHOR]

Background: Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.‐focused, or did not include post‐acute costs in their analyses. Our objective was to determine if combined acute and 30‐day post‐acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH. Methods: A single‐center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital‐level care and 30‐days of post‐acute transitional care. Main outcomes were costs of care of the acute and post‐acute 30‐day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics. Results: Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD = 12.3] years vs. 74.6 [SD = 14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI −$10,262 to $30, p = 0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI −$10,758 to −$1196, p = 0.01) lower. Conclusions: HaH combined with 30‐day post‐acute transition care was less costly than inpatient care. [ABSTRACT FROM AUTHOR]

Background: Potentially disruptive medical, surgical, and social events—such as pneumonia, hip fracture, and widowhood—may accelerate the trajectory of decline and impact caregiving needs in older adults, especially among people with dementia (PWD). Prior research has focused primarily on nursing home residents with dementia. We sought to assess the incidence of potentially disruptive events in community‐dwelling people with and without dementia. Methods: Retrospective cohort study of participants aged 65+ enrolled in the Health and Retirement Study between 2010 and 2018 (n = 9346), including a subset who were married–partnered at baseline (n = 5105). Dementia was defined with a previously validated algorithm. We calculated age‐adjusted and gender‐stratified incidence per 1000 person‐years and incidence rate ratios of: 1) hospitalization for pneumonia, 2) hip fracture, and 3) widowhood in people with and without dementia. Results: PWD (n = 596) were older (mean age 84 vs. 75) and a higher proportion were female (67% vs. 57%) than people without dementia (PWoD) (n = 8750). Age‐adjusted incidence rates (per 1000 person‐years) of pneumonia were higher in PWD (113.1; 95% CI 94.3, 131.9) compared to PWoD (62.1; 95% CI 54.7, 69.5), as were hip fractures (12.3; 95% CI 9.1, 15.6 for PWD compared to 8.1; 95% CI 6.9, 9.2 in PWoD). Point estimates of widowhood incidence were slightly higher for PWD (25.3; 95% CI 20.1, 30.5) compared to PWoD (21.9; 95% CI 20.3, 23.5), but differences were not statistically significant. The association of dementia with hip fracture—but not pneumonia or widowhood—was modified by gender (male incidence rate ratio [IRR] 2.24, 95% CI 1.34, 3.75 versus female IRR 1.31 95% CI 0.92,1.86); interaction term p = 0.02). Conclusions: Compared to PWoD, community‐dwelling PWD had higher rates of pneumonia and hip fracture, but not widowhood. Knowing how often PWD experience these events can aid in anticipatory guidance and care planning for this growing population. [ABSTRACT FROM AUTHOR]

Background: One in 20 older adults in the United States is homebound and rarely/never leaves home. Although being homebound decreases the quality of the lived experience of individuals with serious illnesses, little is known about the frequency or likelihood of transitions in or out of homebound status. The objective of this study was to characterize the probability of transitions to and from homebound status among older adults and examine the relationship between dementia status and homebound transitions. Methods: Using 2011–2018 data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal study of aging in the United States, we identified 6375 community‐dwelling Medicare beneficiaries. Homebound status (independent, semi‐homebound (leaving home but with difficulty or help), homebound (rarely or never leaving home), nursing home resident, dead) was assessed annually via self‐report. Transition probabilities across states were assessed using a multistate Markov model. Results: Less than half of homebound individuals remain homebound (probability = 41.5% [95% CI: 39.2%, 43.5%]) after 1 year. One out of four dies (24% [22.3%, 26.0%]) and there is a low probability (3.2% [2.5%, 4.1%]) of transition to a nursing home. Dementia status was associated with increased risk of progression from independence to homebound status (HR: 1.83 [1.01, 3.34]). Dementia was consistently associated with increased probabilities of transitions to death including a two‐fold increased hazards of progression from homebound to death (HR: 2.18 [1.69, 2.81]). Homebound individuals with dementia have a 34.2% [25.8%, 48.1%] probability of death in 5 years, compared with 17.4% [13.7%, 24.3%] among those without dementia. Discussion: Dementia is associated with greater risk of transitioning across homebound states. There is a greater need to support home‐based care for patients with dementia, especially as the ongoing COVID pandemic has raised concerns about the need to invest in alternative models to nursing home care. [ABSTRACT FROM AUTHOR]

Background: Over the past decade, medical care has shifted from institutions into home settings—particularly among persons with dementia. Yet it is unknown how home‐based clinical services currently support persons with dementia, and what factors shape access. Methods: Using the National Health and Aging Trends Study linked to Medicare claims 2012–2017, we identified 6664 community‐dwelling adults age ≥ 70 years enrolled in fee‐for‐service Medicare. Annual assessment of dementia status was determined via self‐report, cognitive interview, and/or proxy assessment. Receipt of four types of home‐based clinical care (home‐based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home‐based clinical services (e.g., behavioral health)) was assessed annually. We compared age‐adjusted rates of home‐based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home‐based clinical care among persons with dementia. Results: Nearly half (44.4%) of persons with dementia received any home‐based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home‐based clinical care than those without dementia including a 5‐fold increased use of HBMC (95% CI = 3.8–6.2) and double the use of SHHC (95% CI = 2.0–2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR = 0.32; 95% CI = 0.11–0.93). Use of HBMC, podiatry, and other home‐based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas. Conclusion: Although almost half of community‐dwelling persons with dementia receive home‐based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the importance of using information and communication technology (ICT) to address daily and healthcare needs. The barriers for older adults in the United States to learn a new technology to go online during the pandemic remain to be studied. Methods: Using data from the 2019–2020 National Health and Aging Trends Study (NHATS), a nationally representative survey of older Medicare beneficiaries aged 65 years and older in the United States, we used multivariable logistic regression models to identify sociodemographic and clinical factors associated with learning a new technology to go online during the COVID‐19 pandemic. Results: Our sample represented 23,547,688 older adults nationally, of which the majority (60.2%) increased ICT use during the COVID‐19 pandemic. However, most older adults (71.8%) did not report learning a new technology to go online. Those who did not learn a new technology to go online had less of an increase in ICT use than those who learned either with help or by themselves (50.7% vs. 78.4% or 89.2% respectively, p < 0.01). The odds of learning a new technology decreased with increasing age (aOR [95%CI] = 0.96 [0.94–0.98]), being male (aOR [95%CI] = 0.56 [0.45–0.72]), having lower than high school educational attainment (aOR [95%CI] = 0.38 [0.29–0.50]), decreasing income levels (aORs ranged from 0.28 to 0.54), and self‐reported fair or poor general health (aOR [95%CI] = 0.65 [0.47–0.90]). Conclusion: The identified sociodemographic and clinical factors could inform targeted intervention strategies to improve ICT use among older adults during the evolving COVID‐19 pandemic and in the future. [ABSTRACT FROM AUTHOR]

The authors discuss the issue of payments by the U.S. Centers for Medicare & Medicaid Services (CMS) for at-home medical visits. They mention the Independence at Home program run by the CMS, the difficulties in presenting information on savings produced by the program, and what needs to happen next.

Background: Although more than seven million older adults struggle or are unable to leave their homes independently, only a small minority access home‐based primary care (HBPC). Despite substantial growth of HBPC, fueled by growing evidence supporting positive patient outcomes and cost savings, the population remains dramatically underserved and many evidence gaps still exist around scope of practice and key issues in care delivery and quality. Understanding the current state of the field is critical to the delivery of high‐quality home‐based care. Methods: We conducted a systematic search of the peer‐reviewed literature on HBPC, published between January 2010 and January 2020, using Medline, CINAHL, Embase, Web of Science, and Scopus online libraries. All studies were evaluated by two members of the research team, and key findings were extracted. Results: The initial search yielded 1730 unique studies for screening. Of these initial results, 1322 were deemed not relevant to this review. Of the 408 studies deemed potentially relevant, 79 were included in the study. Researchers identified five overarching themes: the provision of HBPC, the composition of care teams, HBPC outcomes, the role of telehealth, and emergency preparedness efforts. Conclusion: The need and desire for growth of HBPC has been highlighted by the recent COVID‐19 pandemic. Current research on HBPC finds a diverse scope of practice, successful use of interdisciplinary teams, positive outcomes, and increasing interest in telehealth with many areas ripe for further research. [ABSTRACT FROM AUTHOR]

Background/Objectives: To identify major barriers to video‐based telehealth use among homebound older adults. Design Cross‐sectional survey. Setting: A large home‐based primary care (HBPC) program in New York City (NYC) serving 873 homebound patients living in the community. Participants: Sixteen primary care physicians. Measurements An 11‐item assessment of provider perceptions of patients' experience with and barriers to telehealth. Results: According to physicians in the HBPC program, more than one‐third (35%) of homebound patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first‐time video‐based telehealth encounters between April and June 2020 during the first COVID‐19 surge in NYC. The majority (82%) required assistance from a family member and/or paid caregiver to complete the visit. Among patients who had not used telehealth, providers deemed 27% (n = 153) "unable to interact over video" for reasons including cognitive or sensory impairment and 14% lacked access to a caregiver to assist them with technology. Physicians were not knowledgeable of their patients' internet connectivity, ability to pay for cellular plans, or video‐capable device access. Conclusion: The COVID‐19 pandemic resulted in a large and dramatic shift to video‐based telehealth use in home‐based primary care. However, 4 months into the pandemic a majority of patients had not participated in a video‐based telehealth encounter due to a number of barriers. Patients lacking caregiver support to assist with technology may benefit from novel approaches such as the deployment of community health workers to assist with device setup. Physicians may not be able to identify potentially modifiable barriers to telehealth use among their patients, highlighting the need for better systematic data collection before targeted interventions to increase video‐based telehealth use. [ABSTRACT FROM AUTHOR]

Background/Objectives: The majority of end‐of‐life (EOL) caregiving is provided by unpaid family members. An increasing number of older adults are kinless (without close family/partnerships) and may have insufficient caregiver support to remain at home at the EOL. We therefore determined what proportion of older adults are kinless at the EOL and assessed the association of kinlessness with EOL care. Design: Retrospective analysis of Health and Retirement Study decedents, 2002–2015. Setting: US population‐based sample. Participants: Decedents age 51+ who died within 1 year of interview (n = 3844) and subset who are community‐dwelling at last interview. Measurements: Kinlessness was defined as lacking a spouse/partner and children. Primary outcome measure was location of death. Secondary outcome measures included contextual EOL measures such as symptom burden and caregiver support. Results: A total of 7.4% of decedents were kinless at the EOL. Kinless decedents were more likely to be female, nonwhite, enrolled in Medicaid, living alone, or living in a nursing home prior to death. Although community‐dwelling kinless decedents received fewer hours of caregiving per week at the EOL (34.7 vs. 56.2, p < 0.05) and were more likely to die in nursing homes (18.1% vs. 10.3%, p < 0.05) than those with kin, they did not have higher EOL symptom burden or treatment intensity (e.g., intensive care unit use). In multinomial logistic analysis controlling for demographic and illness characteristics, kinless decedents living in the community before death had a twofold increased risk of dying in the nursing home (odds ratio [OR] = 2.02 [95% confidence interval (CI) = 1.09–3.72]) and a trend toward increased risk of hospital death (OR = 1.60 [95% CI = 0.96–2.69]) versus home setting. Conclusions: Kinless individuals are more likely to die in nursing homes, even if they are living in the community in their last year of life. Expanded long‐term care services and policies are needed to enable all older adults regardless of their family support systems to receive high‐quality EOL care. [ABSTRACT FROM AUTHOR]

Background: Hospital at Home (HaH) is a growing model of care with proven patient benefits. However, for the types of services required to provide an episode of HaH, full Medicare reimbursement is traditionally paid only if care is provided in inpatient facilities. Design: This project identifies HaH services that could be reimbursable under Medicare to inform episodic care within fee‐for‐service (FFS) Medicare. Setting: All data are derived from acute services provided from the Mount Sinai HaH program between 2014 and 2017 as part of a Center for Medicare and Medicaid Innovation (CMMI) demonstration program. Participants: The sample was limited to patients with one of the following five admitting diagnoses: urinary tract infection (n = 70), pneumonia (n = 60), cellulitis (n = 45), heart failure (n = 37), and chronic lung disease (n = 24) for a total of 236 acute episodes. Measurements: HaH services were inventoried from three sources: electronic medical records, Medicare billing and itemized vendor billing. For each admitting diagnosis, four reimbursement scenarios were evaluated: (1) FFS Medicare without a home health episode, (2) FFS Medicare with a home health episode, (3) two‐sided risk ACO with a home health episode, and (4) two‐sided risk ACO without a home health episode. Results: Across diagnoses, there were 1.5–1.9 MD visits and 1.5–2.7 nursing visits per episode. The Medicare FFS model without home health care had the lowest reimbursement potential ($964–$1604) per episode. The Medicare fee‐for‐service within ACO models with home health care had the greatest potential for reimbursement $4519–$4718. There was limited variation in costs by diagnosis. Conclusion and Relevance: Though existing payment models might be used to pay for many HaH acute services, significant gaps in reimbursement remain. Extending the benefits of HaH to the Medicare beneficiaries that are likely to derive the greatest benefit will require new payment models for FFS Medicare. [ABSTRACT FROM AUTHOR]

Background/Objectives: Approximately 2 million people, or 6% of older adults in the United States, are homebound. In cross‐sectional studies, homebound older adults have high levels of morbidity and mortality, but there is little evidence of longitudinal outcomes after becoming homebound. The aim of this research is to prospectively assess over 6 years the dynamics of homebound status, ongoing community residence, and death in a population of community‐dwelling older adults who are newly homebound. Design/setting: Prospective cohort study using 2011–2018 data from the National Health and Aging Trends Study (NHATS), an annual, nationally‐representative longitudinal study of aging in the United States. Participants: Two hundred and sixty seven newly homebound older adults in 2012. Measurements: Homebound status was defined via self‐report as living in the community but rarely/never leaving home in the prior month. Semi‐homebound was defined as leaving the house only with difficulty or help. Results: One year after becoming newly homebound, 33.1% remained homebound, 22.8% were completely independent, 23.8% were semi‐homebound, 2.2% were in a nursing home, and 18.0% died. Homebound status is highly dynamic; 6 years after becoming homebound, 13.5% remained homebound and 65.0% had died. Recovering from being homebound at 1 year was associated with younger age and lower baseline rates of receiving help with activities of daily living, in particular, with bathing. Conclusion: Homebound status is a dynamic state. Even if transient, becoming homebound is strongly associated with functional decline and death. Identifying newly homebound older adults and developing interventions to mitigate associated negative consequences needs to be prioritized. [ABSTRACT FROM AUTHOR]

Background/Objectives: COVID‐19 required rapid innovation throughout the healthcare system. Home‐based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands‐on, model of care to accommodate restrictions on in‐person contact. Our aim was to determine strategies used by New York City (NYC)‐area HBPC practices to provide patient care during the first wave of the COVID‐19 pandemic with the goal of informing planning and preparation for home‐based practices nationwide. Design: Cross‐sectional qualitative design using semi‐structured interviews. Setting: HBPC practices in the NYC metro area during spring 2020. Participants: HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC‐area practices. Measurements: Semi‐structured interviews explored HBPC practices' COVID‐19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end‐of‐life care, telehealth, community‐based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. Results: Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID‐19, such as patient outreach and telehealth. HBPC‐specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in‐person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long‐standing patients. Conclusion: NYC‐area HBPC providers adapted care delivery and operations rapidly during the height of the COVID‐19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges. [ABSTRACT FROM AUTHOR]

IMPORTANCE: A large and growing population of older adults with multimorbidity, cognitive impairment, and functional disability live in the community, but many never or rarely leave their homes. Being homebound is associated with decreased access to medical services, poor health outcomes, and increased mortality. Yet, it is unknown what factors, in particular socioeconomic factors, are associated with new onset of homebound status. OBJECTIVE: To evaluate the association between income and risk of becoming homebound. DESIGN: Observational cohort study using 2011 to 2018 data from the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries aged 65 years and older. SETTING: Population‐based study in the United States. PARTICIPANTS: A total of 7,042 initially nonhomebound community‐dwelling older adults. EXPOSURE: Total annual household income at baseline (in 2011) measured via self‐report. OUTCOME: Annual measure of homebound status, defined as leaving home an average of 1 d/wk or less. RESULTS: Over 7 years, 15.81% of older adults in the lowest income quartile (≤$15,003) became homebound, compared with only 4.64% of those in the highest income quartile (>$60,000). In a competing risks analysis accounting for risks of death and nursing home admission, and adjusted for clinical and demographic characteristics, those in the lowest income quartile had a substantially higher subhazard of becoming homebound than those in the highest income quartile (1.65; 95% confidence interval = 1.20–2.29). Moreover, we see evidence of a gradient in risk of homebound status by income quartile. CONCLUSION AND RELEVANCE: Our work demonstrates that financial resources shape the risk of becoming homebound, which is associated with negative health consequences. In the context of existing income disparities, more support is needed to assist older adults with limited financial resources who wish to remain in the community. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES The Medicare home health benefit provides episodic skilled home‐based clinical care to the growing population of community‐dwelling persons with dementia. As of January 1, 2020, home health payment changed: episodes shortened from 60 to 30 days, and episodes initiated in the community are now reimbursed at lower rates than episodes following institutional stays. We aim to assess the potential impact of these policy changes on this population. DESIGN/SETTING Cross‐sectional study using the Medicare claims‐linked National Health and Aging Trends Study (NHATS). PARTICIPANTS A total of 1,867 NHATS respondents who received home health between 2011 and 2017. MEASUREMENTS Dementia was defined through both self‐report and a validated cognitive assessment through NHATS. We described the demographic, socioeconomic, and health characteristics of older adults with dementia receiving home health compared with those without dementia. We then assessed the association of dementia with both receiving community‐initiated home health (vs postinstitutional) and visit timing during the home health episode. RESULTS: Over a follow‐up period of just over 4 years, 50.2% of persons with dementia used home health compared with 15.3% of persons without dementia. Most home health provided to persons with dementia was initiated in the community (61%), compared with 37% of episodes provided to persons without dementia. Persons with dementia were more likely to receive care in days 31 to 60 of the episode compared with those without dementia. CONCLUSIONS: Shortening episodes and reimbursing community‐initiated episodes at lower rates may disproportionately impact the highly vulnerable population of older adults with dementia, who receive more community‐initiated care over longer time periods. Our work highlights the need to better understand the unique role of home health in meeting gaps in both acute‐ and long‐term care systems for older adults with dementia. J Am Geriatr Soc 68:2303–2309, 2020. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES Hospice care confers well‐documented benefits to patients and their families, but it is underutilized. One potential reason is inadequate family support to make end‐of‐life decisions and care for older adults on hospice at home. We assessed the association between amount of family support and hospice use among a population of decedents and among specific illness types. DESIGN Prospective cohort study using the National Health and Aging Trends Study waves 2011 to 2017, linked to Medicare claims data. SETTING Contiguous United States. PARTICIPANTS A total of 1,868 NHATS decedents. MEASUREMENTS Outcome variable was 1 day or longer of hospice. Family caregiving intensity was measured by self‐reported hours of care per week and number of caregivers. Covariates included probable dementia status and other demographic, clinical, and functional characteristics. RESULTS: At the end of life, hours of family caregiving and numbers of helpers vary widely with individuals with dementia receiving the most hours of unpaid care (mean = 64.5 hours per week) and having 2.4 unpaid caregivers on average. In an adjusted analysis, older adults with cancer receiving 40 hours and more of unpaid care/week as compared with fewer than 6 hours per week were twice as likely to receive hospice care at the end of life (odds ratio = 2.0; 95% confidence interval = 1.0–4.1). This association was not seen among those with dementia or among decedents in general. No significant association was found between number of caregivers and hospice use at the end of life. CONCLUSION: Older adults at the end of life receive a high number of hours of help at the end of life, many from more than one caregiver, which may shape hospice access. Better understanding of disparities in hospice use can facilitate timely access to care for older adults with a serious illness. J Am Geriatr Soc 68:2288–2296, 2020. [ABSTRACT FROM AUTHOR]

OBJECTIVES For patients who require frequent and intensive therapy services after hospitalization, rehabilitation is predominantly provided in skilled nursing facilities (SNFs). Delivering post‐acute rehabilitation in patientsʼ homes offers a potential alternative. Our aim was to describe and evaluate services and functional outcomes and then identify factors associated with the provision of a 30‐day post‐acute care (PAC) bundle of rehabilitation, medical, and social services provided via the Rehabilitation at Home (RaH) program. DESIGN Single‐arm retrospective review of patients participating in the RaH program. SETTING Multidisciplinary home‐based delivery of PAC in Manhattan. PARTICIPANTS Individuals 18 years or older residing in a specified catchment area and qualifying for SNF‐based rehabilitation services from October 2015 to September 2017. RESULTS: A total of 237 patients participated in RaH over 264 episodes of care. Participants were predominantly older than 85 years (57%; mean = 84.2; standard deviation [SD] = 10.0 years) and of non‐Hispanic white (70%) race and ethnicity. Most were admitted after hospitalization (88.2%) for 117 different diagnostic related groups. Average length of stay in RaH was 14.2 (SD = 6.5) days with patients receiving 1.83 (SD = 2.22) medical provider, 1.67 (SD = 1.58) nursing, and 5.24 (SD = 1.05) physical therapist visits weekly. Most of the patients fully or almost fully met their goals for bed mobility (65%), bed transfer (69%), chair transfer (67%), and ambulation (64%) with the majority achieving moderate or considerable (61%) global functional improvement. Achieving moderate or considerable global improvement was negatively associated with dementia diagnosis (odds ratio [OR] =.23; 95% confidence interval [CI] =.08‐.71) and positively associated with higher baseline ambulation (OR = 5.51; 95% CI = 2.22‐13.66). At 30 days, 87.3% of participants were living in the community. CONCLUSION: Delivering SNF‐level post‐acute rehabilitation care in patientsʼ homes for a broad range of diagnoses is feasible and associated with functional improvement. This approach may help older adults maintain living status in the community. J Am Geriatr Soc 68:1584‐1593, 2020. See related editorial by Malone et al. in this issue. [ABSTRACT FROM AUTHOR]

Background/objectives: An estimated 55 million individuals worldwide live with chronic disability associated with traumatic brain injury (TBI), which may include cognitive, behavioral, and social impairments. Reduced participation in social activities is common after TBI; however, few studies have evaluated loneliness among survivors of TBI. The current study aimed to evaluate the association between history of TBI and loneliness and to identify mediators of this association.Methods/design: Retrospective cohort study. Nationally representative sample of N = 724 adults over age 50 years (Health and Retirement Study). Loneliness was evaluated using the 11-item Revised University of California Los Angeles (R-UCLA) Loneliness Scale (range 11-33). Lifetime history of TBI evaluated retrospectively using the Ohio State University TBI Identification Method. We included the following covariates: age, sex, race, and education; and mediators: depressive symptoms, number of comorbidities, chronic pain, difficulty with activities of daily living, and social network index.Results: History of TBI was associated with a 1.28-point (95% CI, 0.46-2.11; P < .05; Cohen's D = 0.284) increase in R-UCLA Loneliness Scale scores after covariate adjustment. Individuals with more recent injuries (within 10 years) and multiple lifetime TBIs reported the highest loneliness scores. In the structural equation model, depressive symptoms partially mediated the relationship between TBI and loneliness. All models were adjusted for US population sampling weights.Conclusions: History of TBI was associated with greater loneliness compared with individuals without TBI in a representative sample of US adults. Managing depressive symptoms and medical consequences of TBI may be a target to ameliorate reporting of loneliness in this population. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Reliable national estimates of hospice use and underuse are needed. Additionally, drivers of hospice use in the United States are poorly understood, especially among noncancer populations. Thus the objectives of this study were to (1) provide reliable estimates of hospice use among adults in the United States; and (2) identify factors predicting use among decedents and within subsamples of cancer and noncancer deaths. DESIGN: We conducted a prospective cohort study using the Health and Retirement Study survey. Excluding sudden deaths, we used data from the 2012 survey wave to predict hospice use in general, and then separately for cancer and non‐cancer deaths. SETTING: Study data were provided by a population‐based sample of older adults from the U.S. PARTICIPANTS: We constructed a sample of 1,209 participants who died between the 2012 and 2014 survey waves. MEASUREMENTS: Hospice utilization was reported by proxy. Exposure variables included demographics, functionality (activities of daily living [ADLs]), health, depression, dementia, advance directives, nursing home residency, and cause of death. RESULTS: Hospice utilization rate was 52.4% for the sample with 70.8% for cancer deaths and 45.4% for noncancer deaths. Fully adjusted model results showed being older (odds ratio [OR] = 1.54), less healthy (OR =.79), having dementia (OR = 1.52), and having cancer (OR = 5.47) were linked to greater odds of receiving hospice. Among cancer deaths, being older (OR = 1.64) and female (OR = 2.54) were the only predictors of hospice use. Among noncancer deaths, increased age (OR = 1.58), more education (OR = 1.56), being widowed (OR = 1.55), needing help with ADLs (OR = 1.13), and poor health (OR =.77) were associated with hospice utilization. CONCLUSION: Findings suggest hospice remains underutilized, especially among individuals with noncancer illness. Extrapolating results to the US population, we estimate that annually nearly a million individuals who are likely eligible for hospice die without its services. Most (84%) of these decedents have a noncancer condition. Interventions are needed to increase appropriate hospice utilization, particularly in noncancer care settings. J Am Geriatr Soc 68:783–793, 2020 [ABSTRACT FROM AUTHOR]

OBJECTIVES: Paid caregivers (eg, home health aides and personal care attendants) provide hands‐on care that helps individuals with dementia live in the community. This study (a) characterizes paid caregiving among community‐dwelling individuals with dementia and (b) identifies factors associated with receipt of paid care. DESIGN: Cross‐sectional analysis. SETTING: The 2015 National Health and Aging Trends Study (NHATS), a nationally representative study of Medicare recipients aged 65 years and older. PARTICIPANTS: Community‐dwelling individuals with dementia (n = 899). MEASUREMENTS: Paid and family caregiving support was determined by participant or proxy report of help received with functional tasks. Multivariable logistic regression was used to examine factors associated with receipt of paid care. NHATS population sampling weights were used to produce national paid caregiving prevalence estimates. RESULTS: Only 25.5% of community‐dwelling individuals with dementia received paid care, and 10.8% received 20 hours or more of paid care per week. For those who received it, paid care accounted for approximately half of the 83 total caregiving hours (paid and family) that they received each week. Among the subgroup of individuals with advanced dementia (those with impairment in dressing, bathing, toileting, and managing medications and finances), nearly half (48.3%) received paid care. Multivariable analysis, adjusting for sociodemographic, family caregiving support, functional, and clinical characteristics, found that the odds of receiving paid care were higher among men (odds ratio [OR] = 1.91; 95% confidence interval [CI] = 1.24‐2.95), the unmarried (OR = 2.20; 95% CI = 1.31‐3.70), those with Medicaid (OR = 2.16; 95% CI = 1.27‐3.66), and those requiring more help with activities of daily living (ADLs) (OR = 1.32; 95% CI = 1.18‐1.48) and instrumental ADLs (OR = 1.29; 95% CI = 1.14‐1.46). CONCLUSIONS: New ways of making paid caregiving more accessible throughout the income spectrum are required to support family caregivers and respect the preferences of individuals with dementia to remain living in the community. J Am Geriatr Soc 68:186–191, 2019 [ABSTRACT FROM AUTHOR]

Background: Alcohol consumption in later life has increased in the past decade, and the relationship between alcohol consumption and mortality is controversial. Recent studies suggest little, if any, health benefit to alcohol. Yet most rely on single–time point consumption assessments and minimal confounder adjustments. Methods: We report on 16 years of follow‐up from the Health and Retirement Study (HRS) cohorts born 1931 to 1941 (N = 7,904, baseline mean age = 61, SD = 3.18). Respondents were queried about drinking frequency/quantity. Mortality was established via exit interviews and confirmed with the national death index. Time‐varying confounders included but were not limited to household assets, smoking, body mass index, health/functioning, depression, chronic disease; time‐invariant confounders included baseline age, education, sex, and race. Results: After adjustment, current abstainers had the highest risk of subsequent mortality, consistent with sick quitters, and moderate (men: HR = 0.74, 95% CI: 0.60 to 0.91; women: HR = 0.82, 95% CI: 0.63 to 1.07) drinking was associated with a lower mortality rate compared with occasional drinking, though smokers and men evidenced less of an inverse association. Quantitative bias analyses indicated that omitted confounders would need to be associated with ~4‐fold increases in mortality rates for men and ~9‐fold increases for women to change the results. Conclusions: There are consistent associations between moderate/occasional drinking and lower mortality, though residual confounding remains a threat to validity. Continued efforts to conduct large‐scale observational studies of alcohol consumption and mortality are needed to characterize the changing patterns of consumption in older age. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the effect of home‐based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long‐term institutionalization (LTI). DESIGN: Case‐cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks. SETTING: Three IAH‐participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC. PARTICIPANTS: HBPC integrated with long‐term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home‐qualified (IAH‐Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC. INTERVENTION: HBPC integrated with LTSS under IAH demonstration incentives. MEASUREMENTS: Measurements include LTI rate and mortality rates, community survival, and LTSS costs. RESULTS: The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH‐Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home‐ and community‐based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed‐to‐expected ratio =.88 [.68‐1.09]). LTI‐free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH‐q participants in NHATS. CONCLUSION: HBPC integrated with long‐term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs. See related editorial by Leff et al. [ABSTRACT FROM AUTHOR]

Objectives: To examine how misidentification of dementia affects estimation of Medicare costs in a largely minority cohort of participants for whom accurate in‐person diagnoses are available. Design: Prospective cohort study. Setting: Washington Heights‐Inwood Columbia Aging Project, a multiethnic, population‐based, prospective study of cognitive aging of Medicare beneficiaries aged 65 and older. Participants: Individuals clinically diagnosed with dementia (n=495) and individuals clinically diagnosed without dementia (n=1,701). Measurements: Medicare claims‐identified dementia was defined according to the presence of any International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for Alzheimer's disease and related dementias in all available claims during the study period. Participant characteristics associated with claims misidentification of dementia were estimated using logistic regression. Effects of dementia misidentification on Medicare expenditures were estimated using generalized linear models. Results: Medicare claims correctly identified 250 of the 495 (51%) dementia cases and 1,565 of the 1,701 (92%) nondementia cases. Sensitivity of claims‐identified dementia was 0.51, and specificity was 0.92. Average annual Medicare expenditures were $14,721 for a beneficiary with a clinical diagnosis of dementia, and $18,208 for a beneficiary with claim‐identified dementia, suggesting an overestimation of $3,487 per person per year when Medicare claims were used to identify dementia. Total annual expenditures for all beneficiaries with claims‐identified dementia were $258,707 lower than that for all those who were clinically diagnosed, suggesting an overall underestimation of total Medicare expenditures if Medicare claims were used to identify dementia. Different types of misidentification have different effects on dementia‐related cost estimates. Average annual expenditures per person were highest for false positives. Conclusion: Misidentification of dementia in Medicare claims is common. Using claims to identify dementia may result in significantly biased estimates of the cost of dementia. J Am Geriatr Soc 67:269–276, 2019. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether end‐of‐life (EOL) experiences in the first spouse in a marriage are associated with EOL experiences in the other spouse. Design: Nationally representative, longitudinal survey. Setting: Health and Retirement Study, Waves 1992–2012 linked to Medicare claims Participants: Community‐dwelling older adults who died (N=4,558), representing 2,279 married heterosexual couples. Measurements: We examined 3 EOL experiences: enrollment in hospice for >3 days before death, lack of advance care planning (ACP) before death, and intensive care unit (ICU) use during the last 30 days of life. We used multiple logistic regression to determine whether the EOL experience of the first spouse was a significant predictor of the EOL experience of the second spouse after adjusting for demographic characteristics, socioeconomic status, health status, and time between the first and second spouses' deaths. Results: First spouses who died were on average 80 years old, and 62% were male; second spouses were on average 85 years old, and 62% were female. After adjustment, second spouses were more likely to use hospice if the first spouse used hospice (odds ratio (OR)=1.68, 95% confidence interval (CI)=1.29–2.20). Second spouses were less likely to have ACP when the first spouse did not have ACP (OR=2.91, 95% CI=2.02–4.21). Hospice and ACP associations were stronger when deaths were closer in time to one another (p‐value for interaction < .05). Second spouses were more likely to use ICU services if the first spouse did (OR=1.80, 95% CI=1.27–2.55). Conclusions: The EOL experiences of older spouses are strongly associated, which may be relevant when framing ACP discussions. J Am Geriatr Soc 66:2360–2366, 2018 [ABSTRACT FROM AUTHOR]

Objective: To examine how patients' location of death relates to health care utilization and spending for surviving spouses.Data Sources/study Setting: Health and Retirement Study (HRS) 2000-2012 linked to the Dartmouth Atlas and Medicare claims data.Study Design: This was an observational study. We matched bereaved spouses whose spouses died in a hospital to those whose spouses died outside the hospital using propensity scores based on decedent and spouse demographic and clinical characteristics, care preferences, and regional practice patterns.Data Collection/extraction Methods: We identified 1,348 HRS decedents with surviving spouses. We linked HRS data from each dyad with Medicare claims and regional characteristics.Principal Findings: In multivariable models, bereaved spouses of decedents who died in the hospital had $3,106 higher Medicare spending 12 months postdeath (p = .04) compared to those whose spouses died outside a hospital. Those surviving spouses were also significantly more likely to have an ED visit (OR = 1.5; p < .01) and hospital admission (OR = 1.4; p = .02) in the year after their spouse's in-hospital death. Increased Medicare spending for surviving spouses persisted through the 24-month period postdeath ($5,310; p = .02).Conclusions: Bereaved spouses of decedents who died in the hospital had significantly greater Medicare spending and health care utilization themselves after their spouses' death. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to describe distressed and underprepared family caregiver's use of and interest in formal support services (eg, professional counseling, education, organizational assistance).Method: Cross-sectional mail survey conducted in communities of 8 cancer centers in Tennessee, Alabama, and Florida (response rate: 42%). Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers reported support service use and completed validated measures of depression, anxiety, burden, preparedness, and health.Results: Caregivers (n = 294) were on average age 65 years and mostly female (73%), White (91%), and care recipients' spouse/partner (60%); patients averaged 75 years were majority male (54%) with lung cancer (39%). Thirty-two percent of caregivers reported accessing services while 28% were "mostly" or "extremely" interested. Thirty-five percent of caregivers with high depressive symptoms (n = 122), 33% with high anxiety symptoms (n = 100), and 25% of those in the lowest quartile of preparedness (n = 77) accessed services. Thirty-eight percent of those with high depressive symptoms, 47% with high anxiety symptoms, and 36% in the lowest quartile of preparedness were "mostly" or "extremely" interested in receiving services. Being interested in support services was significantly associated with being a minority, shorter durations of caregiving, and with higher stress burden.Conclusions: A large proportion of family caregivers, including those experiencing depression and anxiety symptoms and who were underprepared, are not using formal support services but have a strong interest in services. Strategies to increase service use may include targeting distressed caregivers early in their caregiving experience. [ABSTRACT FROM AUTHOR]

Objectives To determine the difference in receipt of activity of daily living ( ADL) assistance between obese and normal-weight older adults. Design Retrospective cohort study. Setting National Health and Aging Trends Study, 2011-2015. Participants U.S. adults aged 65 and older with ADL disability and a body mass index ( BMI) of 18.5 kg/m2 or greater (N = 5,612) Measurements BMI was classified as normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), or obese (≥30.0 kg/m2). Primary outcome was self-reported receipt of help with specific ADLs. Models were adjusted for demographic characteristics (age, sex, race), degree of need (self-reported general health, severity of disability), household resources (income, marriage, people in household, number of children), and cognitive status (dementia, proxy respondent). Results Obese with disabilities had lower rates of receiving assistance with walking inside (odds ratio ( OR) = 0.63, 95% confidence interval ( CI) = 0.50-0.81), walking outside ( OR = 0.76, 95% CI = 0.59-0.97), toileting ( OR = 0.68, 95% CI = 0.52-0.89), and getting in and out of bed ( OR = 0.67, 95% CI = 0.50-0.87) than normal-weight older adults after adjustment for respondent demographic characteristics. Level of need and cognitive status partially explained the associations. In fully adjusted models, older adults with obesity still had significantly lower odds of receiving assistance in getting in and out of bed than normal weight adults ( OR = 0.69, 95% CI = 0.49-0.98). Conclusion Older adults with obesity are less likely to receive assistance for ADL disabilities than their normal-weight counterparts-an important concern because of ongoing demographic changes in the United States. [ABSTRACT FROM AUTHOR]

Objectives To determine the association between homebound status and mortality. Design Cross-sectional. Setting Annual, in-person interviews. Participants A nationally representative sample of community-dwelling, Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study between 2011 and 2013 (N = 6,400). Measurements Two-year mortality and prevalence of homebound status in the year before death are described using three categories of homebound status: homebound (never or rarely left home in the last month), semihomebound (left home with assistance, needed help or had difficulty), and nonhomebound (left home without help or difficulty). Results In unadjusted analyses, 2-year mortality was 40.3% in homebound participants, 21.3% in those who were semihomebound and 5.8% in those who were nonhomebound. Homebound status was associated with greater 2-year mortality, adjusted for sociodemographic characteristics, comorbidities, and functional status (hazard ratio = 2.08; 95% confidence interval = 1.63-2.65, P < .001). Half of older community-dwelling Medicare beneficiaries were homebound in the year before death. Conclusion Homebound status is associated with greater risk of death independent of functional impairment and comorbidities. To improve outcomes for homebound older adults and the many older adults who will become homebound in the last year of life, providers and policymakers need to extend healthcare services from hospitals and clinics to the homes of vulnerable individuals. [ABSTRACT FROM AUTHOR]

Objectives To investigate factors associated with place of death of individuals in the Mount Sinai Visiting Doctors Program ( MSVD). Design A retrospective chart review was performed of all MSVD participants who died in 2012 to assess predictors of place of death in the last month of life. Setting MSVD, a home-based primary and palliative care program in New York. Participants MSVD participants who were discharged from the program because of death between January 2012 and December 2012 and died at home, in inpatient hospice, or in the hospital (N = 183). Measurements Electronic medical records were reviewed to collect information on demographic characteristics, physician visits, and end-of-life conversations. Results Of 183 participants, 103 (56%) died at home, approximately twice the national average; 28 (15%) died in inpatient hospice; and 52 (28%) died in the hospital. Bivariate analyses showed that participants who were white, aged 90 and older, non-Medicaid, or had a recorded preference for place of death were more likely to die outside the hospital. Diagnoses and living situation were not significantly associated with place of death. Multivariate logistic regression analysis showed no statistical association between place of death and home visits in the last month of life (odds ratio = 1.21, 95% confidence interval = 0.52-2.77). Conclusion Home-based primary and palliative care results in a high likelihood of nonhospital death, although certain demographic characteristics are strong predictors of death in the hospital. For MSVD participants, home visits in the last month of life were not associated with death outside the hospital. [ABSTRACT FROM AUTHOR]

Objectives To determine the prevalence of end-of-life ( EOL) conversations with older adults. Design National Health and Aging Trends Study ( NHATS), a prospective, longitudinal survey of Medicare beneficiaries. Setting Nationally representative. Participants A sample drawn from Wave 2 of the NHATS. Measurements The main outcome was the report of an EOL planning discussion, based upon the participant's response to the question 'Have you talked to anyone about the types of medical treatment you would want or not want if you became seriously ill in the future?' Results Sixty-one percent of the sample (n = 1,993 individuals, weighted n = 11,123,910) responded that they had discussed EOL treatment preferences with someone. In multivariate regression, factors associated with reporting an EOL discussion included being younger (adjusted odds ratio ( AOR) = 1.70, 95% confidence interval ( CI) = 1.17-2.47), having more education (high school degree: AOR = 1.45, 95% CI = 1.02-2.07; some college: AOR = 2.03, 95% CI = 1.40-2.95), and having multiple chronic conditions ( AOR = 1.25, 95% CI = 1.01-1.55). Black race was associated with lower odds of reporting a discussion ( AOR = 0.46, 95% CI = 0.33-0.65). Conclusion Forty percent of a nationally representative sample of Medicare beneficiaries had not discussed their preferences regarding EOL medical treatment. Promoting these conversations in clinical and nonclinical settings will be important to ensure that health care is delivered to individuals in a person-centered manner. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study is to examine the relative contribution of functional impairment and cognitive deficits on risk of hospitalization and costs. Methods A prospective cohort of Medicare beneficiaries aged 65 and older who participated in the Washington Heights-Inwood Columbia Aging Project (WHICAP) were followed approximately every 18 months for over 10 years (1805 never diagnosed with dementia during study period, 221 diagnosed with dementia at enrollment). Hospitalization and Medicare expenditures data (1999-2010) were obtained from Medicare claims. Multivariate analyses were conducted to examine (1) risk of all-cause hospitalizations, (2) hospitalizations from ambulatory care sensitive (ACSs) conditions, (3) hospital length of stay (LOS), and (4) Medicare expenditures. Propensity score matching methods were used to reduce observed differences between demented and non-demented groups at study enrollment. Analyses took into account repeated observations within each individual. Results Compared to propensity-matched individuals without dementia, individuals with dementia had significantly higher risk for all-cause hospitalization, longer LOS, and higher Medicare expenditures. Functional and cognitive deficits were significantly associated with higher risks for hospitalizations, hospital LOS, and Medicare expenditures. Functional and cognitive deficits were associated with higher risks of for some ACS but not all admissions. Conclusions These results allow us to differentiate the impact of functional and cognitive deficits on hospitalizations. To develop strategies to reduce hospitalizations and expenditures, better understanding of which types of hospitalizations and which disease characteristics impact these outcomes will be critical. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To examine the effects of caregiver and patient characteristics on caregivers' medical care use and cost. Methods One hundred forty-seven caregiver/patient dyads were followed annually for 6 years in three academic Alzheimer's disease centers in the United States. Logistic, negative binomial, and generalized linear mixed models were used to examine overall effects of caregiver/patient characteristics on caregivers' hospitalizations, doctor visits, outpatient tests and procedures, and prescription and over-the-counter medications. Results Patients' comorbid conditions and dependence were associated with increased health-care use and costs of caregivers. Increases in caregiver depressive symptoms are associated with increases in multiple domains of caregivers' health-care use and costs. Discussion Findings suggest expanding our focus on dementia patients to include family caregivers to obtain a fuller picture of effects of caregiving. Primary care providers should integrate caregivers' needs in health-care planning and delivery. Clinical interventions that treat patients and caregivers as a whole will likely achieve the greatest beneficial effects. [ABSTRACT FROM AUTHOR]

Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician-led academic home-based primary care practice was restructured into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team-based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound. [ABSTRACT FROM AUTHOR]