Impact of state HCBS generosity on dementia outcomes and disparities

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Project Summary/Abstract Nearly 6 million people in the United States currently live with Alzheimer's disease or related dementia (ADRD) and this number will be more than doubled by 2050. Patients with ADRD have difficulties with memory, language, problem-solving and other cognitive skills that affect their abilities to perform daily activities. Since over 70% of older patients with ADRD live at home and receive the majority of their care in the community, appropriate home- and community-based services (HCBS) for patients with dementia are critical to meet their preference to age in place, avoid unnecessary institutional care use, and reduce caregiver burdens. About 19% of older adults live in rural areas in the US, and older adults living in rural areas tend to have higher rate of dementia and worse cognitive functioning performance than those living in urban areas. Moreover, about 24% of community-living older adults with ADRD are low income and qualify for state Medicaid financial eligibility criteria, and an increasing percentage of people with ADRD are racial/ethnic minorities. A vast body of literature in the past several decades has reported rural-urban, racial/ethnic, and income disparities in important health outcomes, such as unmet needs for basic daily activities, and hospitalizations among community-living older adults with ADRD. These disparities persist in recent years. The two major state programs that support HCBS for older/disabled adults – Medicaid long-term services and supports (LTSS) coverage and Title III programs under the Older Americans Act (OAA) of 1965 – are shown to help improve health outcomes and quality of life for community-living older adults. These two programs together target low- income aged/disabled persons and others with the greatest economic and social needs. It is thus expected that the increased generosity of the two state HCBS programs will benefit the most vulnerable subgroups of older adults in particular, such as those with severe cognitive impairments or rural residents, and help reduce disparities in health outcomes. However, empirical evidence does not exist on whether more generous state HCBS policies help reduce the differences in health outcomes between ADRD and non-ADRD patients or redress the persistent outcome disparities related to rural residence, race/ethnicity, and poverty among community-living ADRD patients. This study proposes to fill this knowledge gap by determining the longitudinal and cross sectional impact of overall state generosity in supporting HCBS through the two major programs, as well as the generosity of individual subtypes of HCBS programs (e.g. home-delivered meals under the OAA), on gaps in health outcomes among a nationally representative sample of Medicare beneficiaries (age≥65 years) with or without ADRD living in the community. Findings of this project will illuminate the ways with which major state HCBS policies impact the equity and outcomes of care received by community-living ADRD patients, and inform future efforts aimed to improve the effectiveness of state HCBS programs.