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Objective: To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). Data Sources: 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Data Collection/Extraction Methods: Not Applicable. Study Design: We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. Principal Findings: Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% Cl:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. Conclusions: Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes. KEYWORDS disability, post-acute care; functional improvement; health disparities; home health agency; Medicare home health, 1 | INTRODUCTION One of the primary responsibilities of home health (HH) is to improve the functional status of HH patients. Home health care is the provision of skilled care [...]

Objective: To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection. Data Sources: We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website. Data Collection/Extraction Methods: We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users. Study Design: This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs. Principal Findings: The introduction of star ratings was associated with a 0.88-per-centage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries. Conclusions: The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection. KEYWORDS home health care, patient experience, provider selection, public reporting, quality of care, star ratings, What is known on this topic * Although the Centers for Medicare and Medicaid Services (CMS) spends over $18 billion annually to care for 3.4 million home health beneficiaries, we [...]

Objective: To document dementia-relevant state assisted living regulations and their changes over time as they pertain to licensed care settings. Data Sources: For all states, current directories of licensed assisted living communities and state regulations for each year, 2007-2018, were obtained from state agency websites and Nexis Uni, respectively. Study Design: We identified multiple types of regulatory classifications for each state and documented the presence or absence of specific dementia care provisions in the regulations for each type by study year. Maps and summary statistics were used to compare results to previous research and document change longitudinally. Data Collection/Extraction Methods: We used a policy analysis approach to connect communities listed in directories to applicable regulatory text. Then, we employed policy surveillance and question-based coding to record the presence or absence of specific policies for each classification and study year. Principal Findings: Our team empirically documented provisions requiring dementia-specific training for administrators and direct care staff, and cognitive impairment screening for each study year. We found that 23 states added one or more of these requirements for one or more license types, but the states that had these provisions for all types of licensed assisted living declined from four to two. Conclusions: We identified significant, previously undocumented, within-state policy variation for assisted living licensed settings between 2007 and 2018. Using the regulatory classification instead of the state as the unit of analysis revealed that many policy adoptions were limited to dementia-designated settings. This suggests that people living with dementia in general assisted living are not afforded the same protections. We call our approach health services regulatory analysis and argue that it has the potential to identify gaps in existing policies, an important endeavor for health services research in assisted living and other care settings. KEYWORDS assisted living facilities, government regulation, health policy, health services, legal epidemiology, residential facilities, 1 INTRODUCTION Assisted living describes a wide variety of residential settings that provide long-term services and supports to older adults, including people living with dementia. These communities can offer social, [...]

Objective: To examine characteristics that are associated with receipt of Aid and Attendance (A&A), an enhanced pension benefit for Veterans who qualify on the basis of needing daily assistance, among Veterans who receive pensions. Data sources: Secondary data analysis of 2016-2017 national VA administrative data linked with Medicare claims. Study design: Observational study examining sociodemographic, medical, and healthcare utilization characteristics associated with receipt of A&A among Veterans receiving pension. Principal findings: In 2017, 9.7% of Veterans with pension newly received the A&A benefit. The probability of receiving A&A among black and Hispanic pensioners was 4.6 percentage points lower than for white pensioners (95%CI = -0.051, -0.042). Married Veterans receiving pension had a 4.4-percentage point higher probability of receiving A&A (95%CI = 0.039, 0.048). Most indicators of need for assistance (eg, home health utilization, dementia, stroke) were associated with significantly higher probabilities of receiving A&A, with notable exceptions: pensioners with a diagnosis of Post-Traumatic Stress Disorder (marginal effect = -0.029 95%CI = -0.037, -0.021) or enrolled in Medicaid (marginal effect = -0.053, 95%CI = -0.057, -0.050) had lower probabilities of receiving A&A. Unadjusted and adjusted rates of receiving A&A among Veterans receiving pension varied by VA medical center. Conclusions: This study identified potential inequities in receipt of the A&A enhanced pension among a sample of Veterans receiving pension. Increased Veteran outreach, provider education, and VA office coordination can potentially reduce inequities in access to this benefit. KEYWORDS benefits, disability, long-term care, low income, older adult, social welfare program. Veterans, 1 INTRODUCTION The Department of Veterans Affairs (VA), through its Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA), supports a large population of older Veterans who require long-term care [...]

Objective. Given the tremendous growth in assisted living (AL) over the past 20 years, it is important to understand how expansion has affected the demand for long-term care (LTC) provided in nursing homes (NHs). We estimated the effect of a change in county-level AL beds on the prevalence of private-pay residents and private-pay resident days at the NH-level.Data Sources. National census of large AL providers (25+ beds), and Minimum Data Set combined with Medicare enrollment records and claims from 2007 and 2014.Study Design. Retrospective longitudinal analysis of LTC markets.Principal Findings. Mean AL beds per county increased from 285 to 324, while NHs exhibited a decrease in private-pay residents (20.1 to 17.7 percent) and resident days (21.3 to 17.5 percent). An increase of 1,000 AL beds at the county level is associated with a reduction of 0.44 percentage points in private-pay resident days but is not significandy associated with percent of private-pay residents.Conclusions. These results suggest that increases in AL capacity have potentially allowed NH residents to delay or decrease their privately financed lengths of stay. As demand for AL continues to grow, it will be important to assess the effects on other LTC sectors.Key Words. Assisted living, nursing home, long-term care, The assisted living (AL) sector has experienced tremendous expansion over the past 20 years as a form of long-term care (LTC) for older and disabled Americans. Although the services offered [...]