Using social risks to predict unplanned hospital readmission and emergency care among hospitalized Veterans.

OBJECTIVES: (1) To estimate the association of social risk factors with unplanned readmission and emergency care after a hospital stay. (2) To create a social risk scoring index. DATA SOURCES AND SETTING: We analyzed administrative data from the Department of Veterans Affairs (VA) Corporate Data Warehouse. Settings were VA medical centers that participated in a national social work staffing program. STUDY DESIGN: We grouped socially relevant diagnoses, screenings, assessments, and procedure codes into nine social risk domains. We used logistic regression to examine the extent to which domains predicted unplanned hospital readmission and emergency department (ED) use in 30 days after hospital discharge. Covariates were age, sex, and medical readmission risk score. We used model estimates to create a percentile score signaling Veterans' health-related social risk. DATA EXTRACTION: We included 156,690 Veterans' admissions to a VA hospital with discharged to home from 1 October, 2016 to 30 September, 2022. PRINCIPAL FINDINGS: The 30-day rate of unplanned readmission was 0.074 and of ED use was 0.240. After adjustment, the social risks with greatest probability of readmission were food insecurity (adjusted probability = 0.091 [95% confidence interval: 0.082, 0.101]), legal need (0.090 [0.079, 0.102]), and neighborhood deprivation (0.081 [0.081, 0.108]); versus no social risk (0.052). The greatest adjusted probabilities of ED use were among those who had experienced food insecurity (adjusted probability 0.28 [0.26, 0.30]), legal problems (0.28 [0.26, 0.30]), and violence (0.27 [0.25, 0.29]), versus no social risk (0.21). Veterans with social risk scores in the 95th percentile had greater rates of unplanned care than those with 95th percentile Care Assessment Needs score, a clinical prediction tool used in the VA. CONCLUSIONS: Veterans with social risks may need specialized interventions and targeted resources after a hospital stay. We propose a scoring method to rate social risk for use in clinical practice and future research.

Differential effects of a social work staffing intervention on social work access among rural and highly rural Veterans: A cohort study.

OBJECTIVE: To evaluate the impact on rural Veterans' access to social work services of a Department of Veterans Affairs (VA) national program to increase social work staffing, by Veterans' rurality, race, and complex care needs. DATA SOURCES AND STUDY SETTING: Data obtained from VA Corporate Data Warehouse, including sites that participated in the social work program between October 1, 2016 and September 30, 2021. STUDY DESIGN: The study outcome was monthly number of Veterans per 1000 individuals with 1+ social work encounters. We used difference-in-differences to estimate the program effect on urban, rural, and highly rural Veterans. Among rural and highly rural Veterans, we stratified by race (American Indian or Alaskan Native, Asian, Black, Native Hawaiian or Other Pacific Islander, and White) and complex care needs (homelessness, high hospitalization risk, and dementia). DATA COLLECTION: We defined a cohort of 740,669 Veterans (32,434,001 monthly observations) who received primary care at a participating site. PRINCIPAL FINDINGS: Average monthly social work use was 8.7 Veterans per 1000 individuals. The program increased access by 49% (4.3 per 1000; 95% confidence interval, 2.2-6.3). Rural Veterans' social work access increased by 57% (5.0; 3.6-6.3). Among rural/highly rural Veterans, the program increased social work access for those with high hospitalization risk by 63% (24.5; 18.2-30.9), and for Veterans experiencing homelessness, 35% (13.4; 5.2-21.7). By race, the program increased access for Black Veterans by 53% (6.1; 2.1-10.2) and for Asian Veterans by 82% (5.1; 2.2-7.9). CONCLUSIONS: At rural VA primary care sites with social work staffing below recommended levels, Black and Asian Veterans and those experiencing homelessness and high hospitalization risk may have unmet needs warranting social work services.

Admission and Discharge Practices among Assisted Living Communities: The Role of State Regulations and Organizational Characteristics.

BACKGROUND AND OBJECTIVES: A better understanding of factors associated with assisted living admission and discharge practices can help identify communities that are more likely to allow residents to age in place. This study examined how state regulations and assisted living organizational characteristics relate to community admission and discharge practices for bathing, getting out of bed, and feeding. RESEARCH DESIGN AND METHODS: Using data from a representative sample of 250 assisted living communities in 7 states and a database of assisted living state regulations, we employed multilevel logistic regression models to examine regulatory and organizational correlates of assisted living community admission and discharge practices for three activities of daily living (ADLs [bathing, getting out of bed, and feeding]). RESULTS: States' regulations were not associated with assisted living community admission and discharge practices. However, assisted living communities above the median in the number of personal care staff members per resident were 17% (95% CI: 6.5%, 27.1%) were more likely to admit residents who needed assistance with feeding and 25.5% (95% CI: -37.7, -13.2) less likely to discharge these residents. For-profit communities were more likely to admit residents with bathing and feeding limitations. DISCUSSION AND IMPLICATIONS: Organizational characteristics (e.g., for-profit affiliation, staffing levels) may in part drive admission and discharge practices, especially related to different care needs. The ability to house residents with advanced care needs may be influenced more by the organizational resources available to care for these residents than by states' admission and discharge regulations.

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias.

OBJECTIVES: To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 to 2015. METHODS: We estimated Poisson models examining the relationships of personal care aide, registered nurse (RN), licensed practical nurse (LPN), and total nursing hours with injury-related ED visits. Models were adjusted for resident characteristics (ie, age, race, sex, dual eligibility, presence and number of chronic conditions), AL community characteristics (percentage of residents on Medicaid, average resident acuity), year fixed effects, and assisted living fixed effects. We examined all injury-related ED visits and injury-related ED visits resulting in hospital admission as separate outcomes. RESULTS: The sample included 122,700 person-months, representing 12,144 fee-for-service Medicare beneficiaries with ADRD within 455 different AL communities in Ohio between 2007 and 2015. Median total nursing hours increased from 1.34 in 2007 to 1.69 in 2015. In the fully adjusted model, an increase in 1 RN-hour per resident-day was associated with a decrease in the risk of any injury-related ED visit (incidence rate ratio 0.59, 95% CI 0.36-0.96), representing a 53% decrease. Changes in RN-hours were not associated with injury-related inpatient hospitalizations. Changes in total nursing, LPN, and personal care aide hours were not associated with changes in the risk of injury-related ED visits or inpatient hospitalizations. CONCLUSIONS AND IMPLICATIONS: Increases in RN staffing hours were associated with reduced injury-related ED use among AL residents with ADRD. RNs provide surveillance and care oversight that may help mitigate injury risk, and they are able to physically assess residents at the time of a fall and/or injury, which can preempt unnecessary ED transfers.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma.

Importance: Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown. Objective: To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane Irma. Design, Setting, and Participants: Retrospective cohort study using 2017 Medicare claims data. Participants were a cohort of Florida AL residents who were aged 65 years or older, enrolled in Medicare fee-for-service, and resided in 9-digit zip codes corresponding to US assisted living communities with 25 or more beds on September 10, 2017, the day of Hurricane Irma's landfall. Propensity score matching was used to match evacuated residents to those that sheltered-in-place based on resident and AL characteristics. Data were analyzed from September 2022 to February 2024. Exposure: Whether the AL community evacuated or sheltered-in-place before Hurricane Irma made landfall. Main Outcomes and Measures: Thirty- and 90-day emergency department visits, hospitalizations, mortality, and nursing home admissions. Results: The study cohort included 25 130 Florida AL residents (mean [SD] age 81 [9] years); 3402 (13.5%) evacuated and 21 728 (86.5%) did not evacuate. The evacuated group had 2223 women (65.3%), and the group that sheltered-in-place had 14 556 women (67.0%). In the evacuated group, 42 residents (1.2%) were Black, 93 (2.7%) were Hispanic, and 3225 (94.8%) were White. In the group that sheltered in place, 490 residents (2.3%) were Black, 707 (3.3%) were Hispanic, and 20 212 (93.0%) were White. After 1:4 propensity score matching, when compared with sheltering-in-place, evacuation was associated with a 16% greater odds of emergency department visits (adjusted odds ratio [AOR], 1.16; 95% CI, 1.01-1.33; P = .04) and 51% greater odds of nursing home visits (AOR, 1.51; 95% CI, 1.14-2.00; P = .01) within 30 days of Hurricane Irma's landfall. Hospitalization and mortality did not vary significantly by evacuation status within 30 or 90 days after the landfall date. Conclusions and Relevance: In this cohort study of Florida AL residents, there was an increased risk of nursing home and emergency department visits within 30 days of Hurricane Irma's landfall among residents from communities that evacuated before the storm when compared with residents from communities that sheltered-in-place. The stress and disruption caused by evacuation may yield poorer immediate health outcomes after a major storm for AL residents. Therefore, the potential benefits and harms of evacuating vs sheltering-in-place must be carefully considered when developing emergency planning and response.

Trends and geographic differences in social work telehealth utilization.

We plotted trends in social work telehealth use among Veterans in a U.S. national social work staffing program and examined the relationship between geographic factors (rurality and neighborhood disadvantage) and telehealth use (audio and video) using linear probability models. Social work telehealth use increased among Veterans during the COVID-19 pandemic. There were no geographic differences in telephone telehealth use. Video telehealth use was less common among Veterans in isolated rural areas and among Veterans in highly disadvantaged areas. Outreach efforts can address barriers that Veterans who live in rural and disadvantaged areas may experience in using video telehealth.

A National Typology of Health Service Regulation in Assisted Living.

BACKGROUND AND OBJECTIVES: State-regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents' outcomes across similarly regulated communities. RESEARCH DESIGN AND METHODS: We used qualitative and quantitative methods to empirically develop and describe a typology of state AL regulations that captures inter- and intrastate variation. Based on the rules governing health services, we created regulatory specificity scores for 5 thematic dimensions: medication administration, third-party care, skilled nursing, medication review, and licensed nurse staffing. With these scores, we conducted a K-means cluster analysis to identify groups of AL license types. To differentiate the regulatory types, we calculated standardized mean differences across structure, process, outcome, and resident characteristics of the AL communities licensed under each type. RESULTS: We identified 6 types of AL differentiated by the regulatory provisions governing health services: Housing, Holistic, Hybrid, Hospitality, Healthcare, and Health Support. The types align with previous work and reflect tangible differences in resident characteristics, health service structures, processes, and outcomes. DISCUSSION AND IMPLICATIONS: This typology effectively captures differences across regulated dimensions and can inform and support quality of care. Researchers, policy-makers, and consumers may benefit from using this typology and acknowledging these differences in AL licensure when designing research studies, developing policies, and selecting an AL community.

Benefits and challenges in the use of RE-AIM for evaluation of a national social work staffing program in the veterans health administration.

Background: In the Department of Veterans Affairs (VA) Veterans Health Administration (VHA), social workers embedded in primary care teams address social and emotional needs that are associated with health outcomes. The mission of the National Social Work PACT Staffing Program is to improve access to social work services for rural Veterans by supporting additional social work staffing in VA medical centers serving rural areas. Methods: We obtained data from the VA corporate data warehouse on Veterans' characteristics and health care use from 2016 to 2022 for all Veterans who received primary care at a Veterans Affairs Medical Center (VAMC) or associated clinic that received funding from the program. We evaluated the program according to RE-AIM constructs as follows: Reach [total number of Veterans who engaged with PACT social work and representativeness with regard to race, rural residence, chronic conditions and health behaviors, and hospital and emergency department (ED) use in the previous 12 months]; Effectiveness (impact of the program on key health care use outcomes which include hospitalizations, emergency department visits, and palliative care); Adoption (number of VA medical centers and outpatient clinics serving rural Veterans that have participated in the program, and number and representativeness of sites eligible for program participation that have not yet received funding); Implementation (adherence to standardized note templates), and Maintenance (permanent social work positions created by the program and continued technical support). Results: In 2022, the program engaged with 30,982 Veterans, 65% of whom lived in rural areas. The program increased social work encounters, reduce hospital and emergency department use, and increase use of palliative care services among Veterans. Key elements of implementation include proactive outreach to Veterans with high-risk indicators and assessment for social risk factors using standardized, national note templates. In terms of maintenance, the program continues to provide data and technical assistance to 23 sites and has created 171 permanent social work positions. Conclusions and implications: The Social Work PACT Staffing Program demonstrates positive outcomes and program sustainment. The RE-AIM framework was a useful tool to evaluate the program, but additional adaption was needed to fit the program's needs.

Self-perception of aging and perceived medical discrimination.

BACKGROUND: Individuals who perceive medical discrimination often face adverse consequences. How individuals perceive their own aging experiences may influence perceived medical discrimination due to age by generating expectations that they will receive poor treatment from clinicians, which may be amplified for individuals who also perceive discrimination because of race. This study explored the relationship between self-perceptions of aging (SPA) and perceived medical discrimination due to age, race, and other reasons. METHODS: We used three waves (2008, 2012, 2016) from the nationally representative Health and Retirement Study (HRS) data. Our sample included 10,188 community-residing individuals aged 51 and over. SPA were measured by two domains: positive SPA and negative SPA. Multinomial logistic regression that adjusted for demographic, health characteristics, and year-fixed effects was conducted to estimate the relationship between SPA and categories of perceived medical discrimination (age, race, age and race, and other). RESULTS: Approximately 11% of the population perceived discrimination because of age or race in the medical setting from 2008 to 2016. Older adults who had a positive SPA were 15% [Adjusted relative risk ratio (ARR): 0.85, 95% CI: 0.79-0.91], 13% [ARRR: 0.87, 95% CI: 0.76-1.00], and 20% [ARRR: 0.80, 95% CI: 0.74-0.88] less likely to experience perceived medical discrimination due to age, race, and the intersection of age and race, respectively, than those who did not, holding other factors constant. Those who held a negative SPA were 38% [ARRR: 1.38, 95% CI: 1.28-1.48] more likely to report perceived medical discrimination due to age and 12% [ARRR: 1.12, 95% CI: 1.03-1.21] more likely to report perceived medical discrimination due to other reasons. CONCLUSIONS: Holding a positive perception of aging may help reduce perceived medical discrimination because of age and race, which may in turn improve communication and lead to timely and appropriate treatment.

Identifying a National Cohort of Medicare Beneficiaries Residing in Assisted Living Settings: An Updated Method.

OBJECTIVE: Present an updated approach to identifying Medicare beneficiaries residing in licensed assisted living (AL) settings in the United States. DESIGN: Retrospective cohort study using a national list of licensed AL settings, US Postal Service (USPS) data, and enrollment, claims, and assessment data from the Centers for Medicare and Medicaid Services. SETTING AND PARTICIPANTS: A total of 403,326 beneficiaries residing in 29,905 licensed AL settings. METHODS: We identified every ZIP+4 code affiliated with each AL address. We then identified all of the Medicare beneficiaries with that ZIP+4 on January 1, 2019, and excluded beneficiaries in nursing homes and hospitals on that date. We identified beneficiaries who were "definitively" and "very likely AL residents" according to the number of addresses corresponding to the ZIP+4 in the USPS data, the capacity of the AL setting, and the presence of a claim or assessment indicating services were delivered in AL. We compared beneficiaries excluded during our new capacity restriction step (ie, "possibly neighbors") to those included as being "definitively" and "very likely AL residents" using standardized mean differences. RESULTS: The cohort excluded (ie, "possibly neighbors") using our new step in the identification process appears to be younger and healthier than the cohorts we include as being "definitively" and "very likely AL residents." In addition, the cohort we identified through our added step of supplementing with claims and assessment data have similar demographics to the other cohorts we include, although they appear to be in poorer health. CONCLUSIONS AND IMPLICATIONS: Leveraging licensed capacity information and supplementing with claims and assessment data produce greater confidence in the ability to accurately identify AL residents using ZIP+4 codes reported in Medicare administrative data.

Association of Medicaid Financing and Concentration of Assisted Living Residents Dually Eligible for Medicare and Medicaid.

This cross-sectional study examines different levels of state Medicaid financing for assisted living and the association with the number of beneficiaries with dual Medicare and Medicaid eligibility who live in assisted living facilities.

Injury-related emergency department use among assisted living residents with Alzheimer's disease and related dementias.

BACKGROUND: Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL. METHODS: Using Medicare claims, we identified a cohort of fee-for-service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site-specific information on memory care designation (n = 116,754). Outcomes included all injury-related ED visits and injury-related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury-related ED visits. RESULTS: The adjusted risk of injury-related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury-related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury-related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL. CONCLUSIONS: Injury-related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD.

The relationship between exposure to Hurricane Harvey and mortality among nursing home residents.

BACKGROUND: Nursing home (NH) residents are vulnerable to mortality after natural disasters. We examined NH residents' excess all-cause mortality associated with Hurricane Harvey, a unique disaster with long-lasting flooding effects. We also explored how mortality differed between short-stay and long-stay residents and by chronic conditions. METHODS: We conducted a retrospective observational study of Texas NH residents, comparing 30- and 90-day mortality among residents exposed to Hurricane Harvey in August 2017 to residents not exposed in the same location and time period during the previous 2 years. Data came from the Minimum Data Set Assessments and the Medicare Beneficiary Summary File. We used linear probability models to examine the association between hurricane exposure and mortality, adjusting for resident demographics, clinical acuity, and NH fixed effects. Models were stratified by short-stay and long-stay status. We also described differences in mortality by residents' chronic conditions. RESULTS: In 2017, 18,479 Texas NH residents were exposed to Hurricane Harvey. Exposure to Hurricane Harvey was not significantly associated with 30-day mortality. However, 7.6% (95% CI: 7.2, 7.9) of long-stay residents died 90 days after exposure to Harvey, compared to 6.3% (95% CI: 6.0, 6.7) during 2015. Apparently, this effect was driven by chronic obstructive pulmonary disease (COPD) as approximately 9.2% of these residents died within 90 days after Harvey landing compared to 7.2% in 2015 (p < 0.01). CONCLUSIONS: Hurricane exposure appears to have significant consequences for mortality among long-stay NH residents, which appear to materialize over the long-term (90 days post-hurricane in our study) and may not be apparent immediately (30 days post-hurricane in our study). NH residents with COPD may be particularly vulnerable to increased mortality risk following hurricane exposure. The results highlight the need to pay special attention to mortality risk in NH residents, particularly those with COPD, following hurricane exposure.

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

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

Determinants of COVID-19 testing among late middle-aged and older adults: Applying the health belief model.

Objectives: The purpose of this study was to examine correlates of taking a COVID-19 test among late middle-aged and older adults using nationally representative data. Methods: Data were obtained from the 2020 Health and Retirement Study midway release COVID-19 module. Our sample was representative of community residing adults aged 51 and over in the United States (n = 2,870). Measurements: We regressed taking a COVID-19 test on demographic characteristics, medical comorbidities, and measures related to the health belief model (i.e., perceived severity, perceived susceptibility, cues to action, and perceived barriers) using logistic regression, stratifying the model by 10-year age categories. Results: Concern about the pandemic was associated with an increase in the likelihood of taking a test among late middle-aged adults. Knowing someone who was diagnosed with COVID-19 was associated with taking a test in most age categories. Financial barriers and knowing someone who died of COVID-19 were not associated with taking a test. Conclusions: How late middle-aged and older adults perceive the COVID-19 pandemic may significantly influence their likelihood of taking a COVID-19 test.

Urban and Rural Differences in Trajectories of Depressive Symptoms in Later Life in the United States.

OBJECTIVE: This research has two primary goals: to examine the relationship between urban residence and trajectories of depressive symptoms and to investigate whether this relationship differs by social isolation and loneliness. METHOD: Data are from 2006, 2008, 2010, 2012, 2014, and 2016 waves of the Health and Retirement Study (HRS), a nationally representative sample of U.S. adults aged 51+ (n = 3,346 females and 2,441 males). We conduct latent growth curve analysis to predict both baseline and trajectories of depression based on urban or rural residency. RESULTS: Residing in urban or rural areas is neither significantly associated with baseline nor the development of late-life depressive symptoms. For females, the relationship between urban residence and baseline depressive symptoms is explained by socioeconomic factors. DISCUSSION: Findings of this study serve to better understand how social and geographic contexts shape long-term well-being of older adults.

Childhood Socioeconomic Status and Physical Activity in Later Life: The Role of Perceived Neighborhood Cohesion and Wealth in Adulthood.

The literature indicates that perceived neighborhood social cohesion is related to later life physical activity. However, there is no research that examines the role of childhood socioeconomic status (SES) in shaping this relationship. We use data from the Health and Retirement Study (2006-2016; N = 8,754) and a structural equation modeling approach to examine whether perceived neighborhood social cohesion and adulthood wealth mediate the relationship between childhood SES and physical activity. Perceived neighborhood social cohesion and adulthood wealth have small but statistically significant mediational effects in the relationship between childhood SES and physical activity. Research on the relationship between health and place should consider the potential impact of childhood circumstances on the neighborhood one lives in during adulthood.

Dementia diagnosis in the hospital and outcomes among patients with advanced dementia documented in the Minimum Data Set.

BACKGROUND: Individuals with dementia do not always have a diagnosis of dementia noted on their hospital claims. Whether this lack of documentation is associated with patient outcomes is unknown. We examined the association between a dementia diagnosis listed on a hospital claim and patient outcomes among individuals with a Minimum Data Set (MDS) assessment. METHODS: A retrospective cohort study was conducted using administrative claims data and nursing home MDS assessments. Hospitalized patients aged 66 and older with advanced dementia noted on an MDS assessment completed within 120 days prior to their first hospitalization in 2017 were included. Advanced dementia was defined based on an MDS diagnosis of dementia, dependency in four or more activities of daily living, and a Cognitive Function Scale score indicative of moderate to severe impairment. Multilevel regression with a random intercept at the hospital level was used to examine the relationship between documentation of dementia in inpatient hospital Medicare claims and the following patient outcomes after adjusting for patient and hospital characteristics: invasive mechanical ventilation (IMV) use, intensive care unit or coronary care unit (ICU/CCU) use, 30-day mortality, and hospital length of stay (LOS). RESULTS: In 2017, among 120,989 patients with advanced dementia and a nursing home stay, 90.57% had a dementia diagnosis on their hospital claims. In adjusted models, documentation of a dementia diagnosis was associated with lower use of the ICU/CCU (adjusted odds ratio [AOR]: 0.78 [95% confidence interval 0.74, 0.81]), use of IMV (AOR: 0.50 [0.47, 0.54]), and 30-day mortality (AOR: 0.81 [0.77, 0.85]). Patients with a dementia diagnosis had a shorter LOS. CONCLUSIONS: Among patients with advanced dementia, those whose dementia diagnosis was documented on their inpatient hospital Medicare claim experienced lower use of ICU/CCU, use of IMV, lower 30-day mortality, and shorter LOS than those whose diagnosis was not documented.

Intergenerational Ambivalence and Loneliness in Later Life.

OBJECTIVE: This brief report examined the relationship between intergenerational ambivalence and loneliness in later life among a group of older adults with at least one child. BACKGROUND: Previous work has explored the links between intergenerational ambivalence and other indicators of well-being but has not examined loneliness. Although studies show an association between positive and negative relationship quality with children and loneliness, there are conflicting findings, and there is also insufficient exploration of the role of gender. METHOD: Utilizing pooled data from the 2012 and 2014 waves of the Health and Retirement Study (HRS) (n = 10,967) (https://hrs.isr.umich.edu/documentation), structural equation models were used to examine the hypothesized relationships, and multiple group analysis was utilized to assess potential gender differences. RESULTS: The results indicated that greater intergenerational ambivalence was associated with increased loneliness in later life. However, there were no significant gender or marital status differences in the relationships. CONCLUSION: This study adds to the existing literature on ambivalence and well-being by showing that ambivalent relationships are related to loneliness. Results underscore the emotional complexity of parent-child relationships and suggest the need for investigating the consequences of holding contradictory feelings.

The Relationship Between States' Staffing Regulations And Hospitalizations Of Assisted Living Residents.

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