Public Health.

Background: Existing studies on the health care utilization and costs associated with Alzheimer's disease (AD) have treated individuals with AD as a homogeneous group, though recent evidence suggests individuals with AD may be classified into biologically distinct subgroups with differing genetic and clinical profiles. The objective of our study is to examine differences in healthcare utilization and costs across cognitively defined AD subgroups.

Method: We utilize data from the Adult Changes in Thought (ACT) study (1994 - 2020), a population-based longitudinal study of aging and the incidence of and risk factors for dementia.

Public Health.

Background: Nearly 90% of nursing homes in the US experienced severe staffing shortages during COVID-19, which disproportionately affected over 50% of nursing home residents living with Alzheimer's Disease and Related Dementia (ADRD). One major federal policy to support the maintenance of staffing levels during the COVID-19 pandemic was the Paycheck Protection Program (PPP), a $75 billion program that provided loans to small businesses, including nursing homes. Loans were forgivable if at least 60 percent of the loan was spent on payroll providing an incentive to apply resources toward staffing.

Market segmentation by profit status: evidence from hospice.

How do referral networks and medical conditions determine where patients get care? We study this question in the US Hospice Industry, where for-profit hospice programs enroll more long-term care patients and more patients with Alzheimer's disease and related dementia. We find that for-profit hospice enrollees have 23% longer lifetime lengths-of-stay in hospice care than not for-profit hospice enrollees with the same medical conditions, institutional referral source, county of residence, and enrollment year. This and other differences in their end-of-life health care utilization suggest that hospice market segmentation is the result of a patient-specific selection mechanism that is partially independent of institutional barriers to hospice care.

Increasing expenditures on home- and community-based services: Do home care workers benefit?

Objective: To examine the association of Medicaid home- and community-based services (HCBS) expenditures on the home care workforce.

Data Sources/study Setting: We use two national, secondary data sources from 2008 to 2019: state-level Medicaid HCBS expenditures and the American Community Survey, in which we identify direct care workers in the home (i.e.

Medicare expenditures among spouses of persons with dementia.

Background: Spouses of persons living with dementia face intense strains on their well-being compared with similarly aged adults and spouses of partners with no dementia. This strain can impact spouses' health and healthcare needs, and therefore affect their healthcare utilization and expenditures.

Methods: Using data from the Health and Retirement Study linked with Medicare claims, we matched dyads of spouses and their partners with dementia (SPWD) to a comparison group of similar spouses and their partners with no dementia (SPWND).

The role of Medicaid home- and community-based services in use of Medicare post-acute care.

Objective: Medicaid-funded long-term services and supports are increasingly provided through home- and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aimed to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled.

Youth Caregivers of Adults in the United States: Prevalence and the Association Between Caregiving and Education.

A growing proportion of individuals adopt family caregiving roles. Family caregivers are the primary providers of long-term care in the United States yet limited federal policy supports exist, despite the known negative impacts of caregiving. There is also limited information about the prevalence of youth/young adult caregivers and the impacts of caregiving at formative ages in the United States.

Caregiving for dementia: trends pre-post onset and predictive factors of family caregiving (2002-2018).

Persons living with Alzheimer's and other related forms of dementia rely heavily on care from family and friends for assistance with daily activities ("family care"), but little is known about care transitions over time. We analyzed data from the Health and Retirement Study to describe caregiving patterns, from 2 years before dementia onset and up to 6 years after. Using sociodemographic data from the interview prior to dementia onset, we determined if there are significant factors that predict receipt of family care at dementia onset.

Does Consumer Credit Precede or Follow Health Among Older Adults? An Investigation in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Trial.

Background And Objectives: Consumer credit has shown increasing relevance to the health of older adults; however, studies have not been able to assess the extent to which creditworthiness influences future health or health influences future creditworthiness. We assessed the relationships between 4-year pre and postmorbid consumer credit history and self-rated physical and mental health outcomes among older adults.

Research Design And Methods: Generalized estimating equations models assessed pre and postmorbid credit history (credit scores, derogatory accounts, and unpaid accounts in collections) and the onset of poor self-rated health (SF-36 score <50) among 1,740 participants aged 65+ in the Advanced Cognitive Training for Independent and Vital Elderly study from 2001 to 2017, linked to TransUnion consumer credit data.

Does Consumer Credit Precede or Follow Changes in Cognitive Impairment Among Older Adults? An Investigation in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Trial.

Objectives: We assessed the relationships between pre- and post-morbid consumer credit history (credit scores, debts unpaid, or in collections) and classification of mild (or greater) cognitive impairment (MCI).

Methods: Generalized Estimating Equation models assessed pre-and post-morbid credit history and MCI risk among 1740 participants aged 65+ in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study, linked to TransUnion consumer credit data.

Results: Each 50-point increase in credit score was associated with up to 8% lower odds of MCI in the next 3 years.

Effects of Cognitive Training on Alzheimer's Disease and Related Dementias: The Moderating Role of Social Determinants of Health.

We examined whether social determinants of health (SDoH) are associated with Alzheimer's disease and related dementias (ADRD) risk and the effects of cognitive training over a 20-year follow-up period. Data were obtained from 1605 participants in ACTIVE. SDoH measures were created using baseline data at the individual and neighborhood level.

Family spillovers and long-term care insurance.

We examine how long-term care insurance (LTCI) affects informal care use and expectations among the insured individuals and co-residence and labor market outcomes of their adult children. We address the endogeneity of LTCI coverage by instrumenting for LTCI with changes in state tax treatment of LTCI insurance policies. We do not find evidence of reductions in informal care use over a horizon of approximately eight years.

Can a Home-Based Collaborative Care Model Reduce Health Services Utilization for Older Medicaid Beneficiaries Living with Depression and Co-occurring Chronic Conditions? A Quasi-experimental Study.

Depression remains a major public health issue for older adults, increasing risk of costly health services utilization. While home-based collaborative care models (CCM) like PEARLS have been shown to effectively treat depression in low-income older adults living with multiple chronic conditions, their economic impact is unclear. We conducted a quasi-experimental study to estimate PEARLS effect on health service utilization among low-income older adults.

Patient Experience at US Hospitals Following the Caregiver Advise, Record, Enable (CARE) Act.

Importance: Communication with caregivers is often not established or standardized during hospitalization. The Caregiver Advise, Record, Enable (CARE) Act is a state-level policy designed to facilitate communication among patients, caregivers, and clinical care teams during hospitalization to improve patient experience; 42 states have passed this policy since 2014, but whether it was associated with achieving these goals remains unknown.

Objective: To determine whether passage of the CARE Act was associated with improvements in patient experience.

Rural disparities in use of family and formal caregiving for older adults with disabilities.

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.

Medicaid Integrated Purchasing for Physical and Behavioral Health: Early Adopters' Perceptions of Payment Reform Implementation in Washington State.

The Centers for Medicare and Medicaid Innovation (CMMI) gave rise to the State Innovation Models (SIMs). Medicaid Integrated Purchasing for Physical and Behavioral Health, referred to as Payment Model 1 (PM1), was a core payment redesign area of the Washington State SIM project under which our research team was contracted to provide an evaluation. In doing so, we leveraged an open systems conceptual model to assess qualitatively Early Adopter stakeholders' perceived effects of implementation.

Let's Not Repeat History's Mistakes: Two Cautions to Scientists on the Use of Race in Alzheimer's Disease and Alzheimer's Disease Related Dementias Research.

Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) research has advanced gene and biomarker technologies to aid identification of individuals at risk for dementia. This innovation is a lynchpin in development of disease-modifying therapies. The emerging science could transform outcomes for patients and families.

Gender of Study Partners and Research Participants Associated With Differences in Study Partner Ratings of Cognition and Activity Level.

Objectives: Studies of Alzheimer's disease typically include "study partners" (SPs) who report on participants' cognition and function. Prior studies show SP reports differ depending on the relationship between the SP and participant, that is, spouse or adult child. Adult children SPs are typically female.

Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions.

Background: Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations.

Objective: We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating.