Health Care Use After Functional Disability: Opportunities to Improve the Care of Older Adults

项目摘要/摘要 功能性残疾深刻地影响了老年人的健康和保健使用，但功能状态 没有受到卫生系统的始终如一的监测，也没有被联邦医疗保险定期收集。患者及其家属 对于这些未被认识到的需求，往往得不到足够的支持。当特定的疾病或 传统上，多病一直是研究的焦点，研究的重点是高负担和潜在的负担。 卫生保健使用，残疾，定义为需要帮助进行日常生活活动(ADL)，可能是更多 关键的和普遍的因素。残疾和医疗保健使用之间的关系是复杂的：医学 条件可能导致残疾和卫生保健使用，残疾和未得到满足的护理需求可能导致健康 护理使用和住院本身可能导致残疾。卫生系统的特点和实践的变化 模式，如医院床位数量和当地卫生保健强度水平，影响卫生保健模式 在区域一级，并可能影响残疾与卫生保健使用之间的关系。在全国范围内， Medicare Advantage(MA)计划正在迅速扩展，并在以下方面提供了越来越大的灵活性 能够更好地支持残疾老年人的福利。然而，患有功能性残疾的老年人 更有可能离开MA计划，并可能从质量较差的熟练护理设施和家庭健康中接受护理 马萨诸塞州的机构。目前尚不清楚MA计划是否正在将护理从设施转移到社区并转移到无偿 护理人员，以降低成本。保罗·比森新兴领袖老年职业发展奖 我将支持我通过研究残疾与残疾之间的关系来解决这一差距的努力 和卫生保健使用在三个层面：个人、卫生系统和卫生政策。在SA1，我将调查 首次使用医疗保险的ADL残疾报告后医疗保健利用的个体水平异质性 与索赔相关的国家健康和老龄化趋势研究(NHATS)，该研究允许识别 残疾发作。在SA2中，我将使用健康和退休研究以及获取区域特征的数据 评估区域卫生系统特征对残疾后卫生保健利用的影响。在SA3中，我将使用 NHAT链接到医疗保险数据，以检查护理环境的差异(即，社区护理与机构护理) 和照顾(即有偿和无偿照顾)之间的功能残疾老年人在MA与 传统医疗保险。这些科学目标与一项全面的发展计划密切相关，通过该计划，我 将在轨迹分析和分层建模、临床和 对老年残疾、卫生经济学和政策洞察力的系统理解，以及领导技能 将我的发现转化为政策变化。这个为期五年的项目利用了我丰富的经验 基于调查的研究，我的机构的资源，以及我导师的专业知识，以确定 有机会改善对老年人的照顾，同时促进我作为独立人士的发展 致力于改善有功能性残疾的老年人的医疗保险政策的研究人员。

PROJECT SUMMARY/ABSTRACT Functional disability profoundly impacts the health and health care use of older adults, and yet functional status is not consistently monitored by health systems, nor routinely collected by Medicare. Patients and their families frequently struggle with inadequate support for these unrecognized needs. While specific diseases or multimorbidity have traditionally been the focus of research investigating high and potentially burdensome health care use, disability, defined as needing help performing activities of daily living (ADLs), may be a more critical and universal factor. The relationship between disability and health care use is complex: medical conditions may result in both disability and health care use, disability and unmet care needs can lead to health care use, and hospitalization itself can cause disability. Variation in health system features and practice patterns, such as the numbers of hospital beds and local levels of health care intensity, impact care patterns at a regional level and may influence the relationship between disability and health care use. Nationally, the Medicare Advantage (MA) program is rapidly expanding and offers increasing flexibility in supplemental benefits that could better support older adults with disability. However, older adults with functional disability are more likely leave MA plans and may receive care from lower quality skilled nursing facilities and home health agencies in MA. It is unknown if MA plans are shifting care from facilities to the community and to unpaid caregivers in order to reduce costs. The Paul Beeson Emerging Leaders Career Development Award in Aging will support my effort to address this gap through research that will examine the relationship between disability and health care use at three levels: the individual, health system, and health policy. In SA1, I will investigate the individual-level heterogeneity of health care use after the first report of ADL disability using the Medicare claims-linked National Health and Aging Trends Study (NHATS), which allows for identification of the month of disability onset. In SA2, I will use the Health and Retirement Study and data capturing regional characteristics to assess the influence of regional health system features on health care use after disability. In SA3, I will use NHATS linked to Medicare data to examine differences in care setting (i.e., community vs. institutional care) and caregiving (i.e., paid and unpaid caregiving) between older adults with functional disability in MA vs. traditional Medicare. These scientific aims link closely with a comprehensive development plan through which I will gain advanced methodological expertise in trajectory analysis and hierarchical modeling, clinical and systems understanding in geriatric disability, health economics and policy insight, and the leadership skills to translate my findings to policy change. This five-year project leverages my extensive experience conducting survey-based research, the resources of my institution, and the expertise of my mentors to identify opportunities to improve the care of older adults while catalyzing my development as an independent researcher working to improve Medicare policy for older adults with functional disability.