Impact of state HCBS generosity on dementia outcomes and disparities

项目摘要/摘要 美国目前有近600万人患有阿尔茨海默氏症或相关痴呆症 (ADRD)到2050年，这一数字将增加一倍以上。ADRD患者有以下困难 影响他们日常表现能力的记忆、语言、解决问题和其他认知技能 活动。由于超过70%的老年ADRD患者住在家里，他们的大部分护理是在 为痴呆患者提供社区、适当的家庭和社区服务(HCBS)对于 满足他们就地老龄化的偏好，避免不必要的机构护理使用，并减轻照顾者的负担。 在美国，大约19%的老年人生活在农村地区，而生活在农村地区的老年人往往有更高的 痴呆率和认知功能表现比生活在城市地区的人更差。此外， 在患有ADRD的社区老年人中，约24%的人收入较低，有资格享受州医疗补助 资格标准，而且患有ADRD的人中有越来越多的人是少数族裔。一个巨大的躯体 在过去几十年的文学作品中，报告了城乡、种族/民族和收入差距 重要的健康结果，如基本日常活动的需求未得到满足，以及 社区生活的患有ADRD的老年人。这些差距在最近几年持续存在。两大州 为老年人/残障人士提供HCBS支持的计划--医疗补助长期服务和支持(LTSS) 1965年《老年美国人法案》(OAA)下的保险和第三章计划--被证明有助于改善 社区老年人的健康结果和生活质量。这两个计划共同瞄准了低收入 收入老年人/残疾人和其他有最大经济和社会需要的人。因此，预计 两个州的HCBS计划的慷慨程度的增加将使老年人中最脆弱的亚群受益 尤其是成年人，如有严重认知障碍的人或农村居民，并有助于减少 在健康结果方面的差异。然而，没有经验证据表明，是否有更慷慨的国家 HCBS政策有助于减少ADRD患者和非ADRD患者之间的健康结果差异 纠正与农村居住地、种族/族裔和贫穷有关的长期结果差异 社区生活的ADRD患者。这项研究建议通过确定纵向的 以及通过两个主要计划支持母婴传播方案的总体州慷慨的横向影响，如 以及个别亚类型的儿童健康保险计划的慷慨(例如，高龄津贴下的自助餐)， 关于具有全国代表性的医疗保险受益人样本(≥，65岁)的健康结果差距 几年)，无论有没有ADRD居住在社区。这个项目的发现将阐明 国家主要的HCBS政策影响社区生活的ADRD接受护理的公平性和结果 患者，并告知未来旨在提高州HCBS计划有效性的努力。

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.