Impact of Financial Incentives on Setting of Care for Older Adults with Alzheimer's Disease and Related Dementias

阿尔茨海默病和阿尔茨海默病相关痴呆(AD/ADRD)是不可逆转的神经认知 自闭症以记忆力、认知力和独立生活能力逐渐下降为特征的疾病这个 AD/ADRD患者的公共卫生负担巨大，国家费用超过277美元 2018年为1860亿美元，其中包括医疗保险和医疗补助支付的1860亿美元。尽管有这样的投资，承保范围 以家庭和社区为基础的服务往往不足以满足社区居住的需要。 患有AD/ADRD的个体。卫生保健服务(如家庭保健、个人护理服务)可能比 机构护理，更符合患者的意愿，并可能产生更好的结果。更好地访问 HCBS可能会延迟或取代对疗养院护理的需求，从而提高认知和 需要住进疗养院的功能障碍。许多州的医疗补助计划都有 开始实施政策，鼓励从机构护理转向成本较低的母婴传播。然而， 经济激励对AD/ADRD老年患者护理环境(家庭与机构)的影响不是 很好理解。这项拟议的研究利用了纽约州的一项自然实验。介于 2012年和2015年，纽约从按服务收费提供HCBS过渡到管理型长期护理 (MLTC)模式，将成本责任转移到管理型医疗计划。所有医疗补助受益人 需要超过120天的长期护理才能加入MLTC。这项任务是 分阶段实施，从纽约市开始，逐步扩展到该州其他地区。这 自然实验创造了一个独特的机会来研究经济激励对护理设置的影响 (家庭与机构)适用于患有AD/ADRD的老年人。具有双重资格的老年人(65岁以上) 医疗保险和医疗补助计划受到这些激励措施的影响。我们的团队将利用多个纵向数据 实现以下目标的资料来源：1)描述长期护理的覆盖面和利用率的趋势 2010至2019年纽约州被诊断为AD/ADRD的老年人的服务；2)评估 符合双重条件的老年人家庭保健和养老院护理强度(每年天数)的变化 执行MLTC任务后患有AD/ADRD的成年人；3)评估认知功能的变化 AD/ADRD双重符合条件的老年人的功能状态(日常生活活动能力) 在执行MLTC任务后，进入家庭保健或疗养院。这样做的目的是 由调查员发起的新R21将为政策制定者和其他利益相关者提供严格的分析，以 告知财政激励措施的设计，以改善为老年人提供的长期护理服务 AD/ADRD。研究结果将为R01的开发提供参考，以研究财务激励对长期的影响 多个州患有AD/ADRD的老年人的护理利用和结果。

Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD) are irreversible neurocognitive disorders characterized by progressive decline in memory, cognition, and the ability to live independently. The public health burden of care for individuals with AD/ADRD is enormous, with national costs exceeding $277 billion in 2018, including $186 billion paid by Medicare and Medicaid. Despite such investments, coverage of home and community-based services (HCBS) is often inadequate to meet the needs of community-dwelling individuals with AD/ADRD. HCBS (e.g., home health care, personal care services) are likely to be costly than institutional care, more consistent with patient wishes, and may result in better outcomes. Greater access to HCBS may delay or replace the need for nursing home care, thus increasing the level of cognitive and functional impairment that necessitates admission to a nursing home. Many state Medicaid programs have begun to implement policies that incentivize a shift from institutional care to lower-cost HCBS. However, the impact of financial incentives on setting of care (home versus institution) for older adults with AD/ADRD is not well understood. The proposed study takes advantage of a natural experiment in New York state. Between 2012 and 2015, New York transitioned from fee-for-service delivery of HCBS to a managed long term care (MLTC) model that shifted the responsibility for costs to managed care plans. All Medicaid beneficiaries requiring more than 120 days of long term care were required to enroll in MLTC. The mandate was implemented in phases, starting in New York City and gradually expanding to other areas of the state. This natural experiment creates a unique opportunity to study the impact of financial incentives on setting of care (home versus institution) for older adults with AD/ADRD. Older adults (aged 65+) who are dually eligible for Medicare and Medicaid are affected by these incentives. Our team will leverage multiple longitudinal data sources to accomplish the following aims: 1) Describe trends in coverage and utilization of long term care services among older adults in New York state diagnosed with AD/ADRD between 2010 and 2019; 2) Evaluate changes in the intensity of home health care and nursing home care (days per year) among dual eligible older adults with AD/ADRD following implementation of MLTC mandates; 3) Evaluate changes in cognitive function and functional status (ability to perform activities of daily living) among dual eligible older adults with AD/ADRD admitted to home health care or nursing home following implementation of MLTC mandates. The goal of this new investigator-initiated R21 is to provide policymakers and other stakeholders with rigorous analyses to inform the design of financial incentives to improve delivery of long term care services for older adults with AD/ADRD. Findings will inform development of an R01 to study the impact of financial incentives on long term care utilization and outcomes among older adults with AD/ADRD across multiple states.