Impact of state HCBS generosity on dementia outcomes and disparities

项目总结/摘要 美国目前有近600万人患有阿尔茨海默病或相关痴呆症 （ADRD），到2050年，这一数字将增加一倍以上。ADRD患者难以 记忆、语言、解决问题和其他影响他们日常表现能力的认知技能 活动由于超过70%的老年ADRD患者住在家里，并在家中接受大部分护理， 社区，适当的家庭和社区为基础的服务（HCBS）的痴呆症患者是至关重要的， 满足他们对就地养老的偏好，避免不必要的机构护理，减轻照顾者的负担。 大约19%的老年人生活在美国的农村地区，生活在农村地区的老年人往往有更高的 老年痴呆症的发病率和认知功能的表现比生活在城市地区的人差。此外，委员会认为， 大约24%的社区老年ADRD患者是低收入人群，有资格获得州医疗补助金 资格标准，以及越来越多的ADRD患者是种族/少数民族。一个巨大的身体 在过去几十年中，有大量的文献报道了农村与城市、种族/民族和收入差距， 重要的健康结果，如基本日常活动需求未得到满足， 社区老年人ADRD。近年来，这些差距依然存在。两大国 支持老年人/残疾人HCBS的计划- Medicaid长期服务和支持（LTSS） 根据1965年的《美国老年人法案》（OAA）， 社区老年人的健康结果和生活质量。这两个项目的目标都很低- 有收入的老年人/残疾人和其他有最大经济和社会需求的人。因此预期 两个州HCBS计划的慷慨增加将使最弱势的老年人群体受益 特别是成年人，如有严重认知障碍的人或农村居民， 健康结果的差异。然而，经验证据并不存在是否更慷慨的国家 HCBS政策有助于减少ADRD和非ADRD患者之间的健康结果差异， 解决与农村居住、种族/族裔和贫困有关的持续存在的结果差异， 社区ADRD患者。本研究建议通过确定纵向 以及通过两个主要项目支持HCBS的整体国家慷慨的横截面影响， 此外，长者健康及社区为本计划的个别子类别（例如高龄津贴下的送餐上门服务）亦十分慷慨， 在全国代表性的医疗保险受益人样本（年龄≥65岁）中， 有或没有ADRD生活在社区。本项目的研究结果将阐明 主要的州HCBS政策影响社区生活ADRD接受护理的公平性和结果 患者，并告知未来的努力，旨在提高国家HCBS计划的有效性。

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.