Inequities in Home and Community-Based Services Access and Disparities in Alzheimer's Disease and Related Dementias

项目摘要-项目1 阿尔茨海默病和相关痴呆症（ADRD）患者的公共护理资金历来受到青睐。 长期护理设施护理优于社区护理。然而，大多数人表达了这样的愿望， 尽可能长时间地留在社区（而不是机构）。1999年美国最高法院 Olmstead决定，以及几个联邦和州的倡议，以鼓励平衡医疗补助覆盖的长期 服务和支持（LTSS）向社区设置，导致了家庭和社区的稳步扩张， 基于社区的服务（HCBS），包括医疗和非医疗服务，以支持疗养院合格的个人， 他们希望留在社区。机构护理的质量较低，对LTSS的需求更大， 患有ADRD的黑人和西班牙裔成年人以及残疾人。然而，这种扩张的发生， 关于六氯代苯与现有替代品相比如何以及它是否确实减少了 不平等使用混合方法序贯解释性设计和与Medi相关的当代Medicaid数据， 为双重资格受益人提供护理数据，项目1将完成三个目标：目标1。确定行政和 双重符合Medicare资格的受益人的全国样本中HCBS服务接收的自我报告预测因素 以及医疗补助计划，在2010年至2024年之间进行ADRD的基于索赔的诊断。目标二。为了评估差异的影响， HCBS服务接收中对疗养院使用差异、生活质量和功能、不良事件的影响 和社会风险，临终关怀和死亡率的双重合格受益人与索赔为基础的诊断 2010年至2024年之间的ADRD。目标3.探索ADRD患者和护理伙伴的决策过程， 考虑到HCBS的使用和医疗补助管理员，HCBS机构和直接服务提供者对障碍的评估， 为患有严重障碍的受益人扩大卫生保健和康复服务的协调员和促进者。通过探索州和联邦政策， 增强或阻碍LTSS获取和结果公平性的机制，我们将确定政策杠杆， 研究ADRD成人患者中的种族、民族和残疾差异。除了与核心B合作之外 和核心C在这个计划项目补助金（PPG），这项工作也将受益于项目3（估计 区域初级保健质量的ADRD目标1），与项目4合作， 目标2，并与项目2合作，为目标3招募关键线人。通过探索州和联邦 加强或阻碍长期社会服务获得和成果公平的政策和机制， 通过更大的PPG，确定减少成年人种族、民族和残疾差异的政策杠杆 关于ADRD

PROJECT SUMMARY – PROJECT 1 Public financing of care for patients with Alzheimer’s disease and related dementias (ADRD) has historically favored long-term nursing facility care over care provided in the community. Most individuals, however, express the desire to remain in the community (rather than an institution) for as long as possible. The 1999 U.S. Supreme Court Olmstead decision, and several Federal and state initiatives to encourage balancing of Medicaid-covered long-term services and supports (LTSS) toward community settings, have led to a steady expansion of home- and commu- nity-based services (HCBS), including medical and non-medical services to support nursing-home eligible individu- als wishing to remain in the community. The quality of institutional care is lower, and the need for LTSS is greater in Black and Hispanic adults with ADRD, and among people with disabilities. Yet the expansion has occurred without substantial evidence regarding how HCBS compares to available alternatives and whether it does, in fact, reduce inequities. Using a mixed methods sequential explanatory design and contemporary Medicaid data linked to Medi- care data for dual-eligible beneficiaries, Project 1 will complete three aims: Aim 1. To identify administrative and self-reported predictors of HCBS service receipt in a national sample of beneficiaries dually eligible for Medicare and Medicaid with claims-based diagnosis of ADRD between 2010 and 2024. Aim 2. To estimate the impact of dif- ferences in HCBS service receipt on disparities in nursing home use, quality of life and function, adverse events and social risks, end-of-life care, and mortality among dual-eligible beneficiaries with claims-based diagnosis of ADRD between 2010 and 2024. Aim 3. To explore ADRD patient and care partner decision-making processes re- garding HCBS use and Medicaid administrators, HCBS agency, and direct service providers’ assessments of barri- ers and facilitators to HCBS expansion for beneficiaries with ADRD. By exploring state and Federal policies and mechanisms that enhance or impede equity in LTSS access and outcomes, we will identify policy levers for reduc- ing disparities by race, ethnicity, and disability among adults with ADRD. In addition to collaborating with Core B and Core C in this Program Project Grant (PPG), this work will also benefit from data derived in Project 3 (estimates of regional primary care quality for ADRD for Aim 1), collaboration with Project 4 to contextualize acute-care out- comes in Aim 2, and partnership with Project 2 to recruit key informants for Aim 3. By exploring state and Federal policies and mechanisms that enhance or impede equity in LTSS access and outcomes, this project will synergize with the larger PPG to identify policy levers for reducing disparities by race, ethnicity, and disability among adults with ADRD.