Alzheimer's disease and related dementias (ADRD) create challenges for hospital-to-home transitions, caregiver preparation, and home health care coordination. This cross-sectional study examined socioeconomic and geographic inequalities in hospital-level ADRD burden among 3,027 U.S. hospitals serving Medicare fee-for-service beneficiaries. Multivariable quasibinomial regression assessed associations between ADRD prevalence and hospital characteristics, rurality, census region, and patient composition. An age-adjusted sensitivity analysis was conducted among 3,003 hospitals with complete age-composition data. Mean hospital-level ADRD prevalence was 22.00% among patients and 24.00% among events. In the primary model, ADRD prevalence was higher in hospitals in the South and among hospitals serving higher proportions of dual-eligible, female, and White patients. In the age-adjusted sensitivity model, dual eligibility remained strongly associated with ADRD prevalence, while the female-composition association was attenuated. These hospital-level patterns may help identify settings where enhanced discharge planning and home health care coordination should be considered.
Home and community-based services (HCBS) in the United States are required to deliver person-centered practice (PCP) under the HCBS Settings Rule, yet peer-reviewed literature provides limited insight into how PCP workforce competencies are operationalized in HCBS practice. This scoping review synthesized gray literature, including policy briefs, training guides, government documents, and practice resources, to describe PCP competencies and explore barriers and facilitators to implementation in the HCBS workforce. Twenty-eight documents met the inclusion criteria. Most competencies aligned with the five competency domains of the National Center on Advancing Person-Centered Practices and Systems, while additional competencies related to trauma-informed practice, health and safety, staff attributes, and crisis intervention also emerged. Implementation barriers included variation in training requirements, workforce shortages, inconsistent documentation and monitoring, and administrative challenges. Facilitators included standardized training, organizational support, and competency development opportunities. Findings complement evidence from academic research, highlighting recommendations to improve PCP in the HCBS workforce.
Self-rated health (SRH) is an important indicator of overall well-being and is associated with morbidity, functional decline, and mortality. This study examined temporal trends, sociodemographic and behavioral determinants, and age-related differences in fair or poor SRH among adults in Missouri. A repeated cross-sectional analysis was conducted among 56,970 adults aged ≥ 18 years. Survey-weighted logistic regression models were used to assess associations between physical activity and SRH, adjusting for sociodemographic and health-related factors. The prevalence of fair or poor SRH declined from 20.5% in 2018 to 16.2% in 2020 before increasing to 20.1% in 2024. Lower income and unemployment were strongly associated with poor SRH. Physical activity was associated with lower odds of poor SRH, with a stronger protective association observed among adults aged ≥ 65 years. These findings highlight the importance of promoting physical activity to support healthy aging and improve health outcomes among community-dwelling adults.
Telehealth, accelerated by the COVID-19 pandemic, has become essential in-home health care, particularly for individuals with spinal cord injury (SCI). However, traditional telehealth often lacks adequate remote intervention and monitoring for SCI patients. This study evaluated a novel telehealth trial using transcutaneous electrical stimulation (TES) with innovative approaches to improve bladder function in SCI patients. Fifteen participants completed daily 15-minute TES sessions over four weeks, supported by courier-delivered equipment, video conferencing, and online assessments with self-reported monitoring at home. The trial achieved 100% adherence, with 80% of participants expressing confidence in device use and 87% indicating willingness to continue TES. Most participants found the device user-friendly, and 66% reported symptom improvement. This study highlights the potential of telehealth trials to enhance access to care, improve patient outcomes, and promote health equity in home care settings, particularly during periods of restricted in-person healthcare delivery.
The COVID-19 pandemic has had serious consequences for older adults and individuals with chronic conditions, many of whom rely on long-term services and supports. In response to the pandemic, the federal government invested nearly $13 billion dollars for states to expand home and community-based services (HCBS) for older adults and persons with disabilities. States have several options to provide Medicaid-funded HCBS benefits including the 1915(i) HCBS benefit and 1915(k) Community First Choice program. This research uses event history analysis to model state adoption of these two optional Medicaid benefits. The results indicate that a Democratic governor and the state's unemployment rate were associated with states' adoption of the 1915(k) program, while the unemployment rate and the supply of home health agencies were associated with states' adoption of the 1915(i) benefit. Findings highlight similarities in factors associated with Medicaid HCBS program adoption as well as differences stemming from unique program attributes.
Peripheral arterial disease (PAD) causes narrowing of the lower extremity arteries and impacts daily living activities. This retrospective study (April 2023 - April 2024) examined 171 home care patients, with 31.6% diagnosed with PAD. Of these, 37.4% were fully dependent, 36.3% (n = 62) were severely dependent, 16.4% (n = 28) were moderately dependent, 7.0% (n = 12) were mildly dependent, 2.9% (n = 5) were independent, and PAD prevalence was higher among severely dependent patients. Dementia was identified as a significant risk factor for PAD. The high prevalence of PAD among severely dependent individuals suggests a potential link between lifestyle factors and PAD risk. The study highlights the need for further research on whether modifying PAD risk factors can enhance patient independence.
Elderly Health Care Voucher Scheme represents a form of demand-side subsidy given to the elders to choose a spectrum of medical services in the private medical sector. The current paper aims at (a) conducting a needs assessment of the scheme with an analytical framework of the Four A 's approach (i.e., availability, awareness, accessibility, and acceptance regarding a social program) and (b) evaluating whether the outcome measures of the scheme (i.e., the use of private healthcare services, the use of primary care and the empowerment of the elders in the choice of services) were achieved. The needs assessment concludes that the utilization rate of the elders, awareness and satisfaction rate are high. The positive sides concluded from the needs assessment, however, failed to turn into the fulfillment of outcome measures due to the structural barriers. Recommendations at short-term, medium-term and long-term are made.
Community Home-Based Care (CHBC) workers around the world have not been satisfied with their work over the years. In South Africa, unfair labor practices and poor organization of CHBC work have recently led to strikes and unionization by caregivers. At the frontline of caregiving are black working-class women whose dominance illuminates how the intersections of gender, class and race contribute to care workers' precariat position. Regardless of the gendered precarious encounters, the 20 female CHBC workers from Soweto, South Africa, who participated in this study, are optimistic and resilient. This article visibilizes the optimism, resilience, positivity, self-empowerment, control, the gendered power, and agency that care workers exercise in response to the challenges that characterize care work. Beyond merely illuminating the gendered oppositional binaries, the article calls for the deconstruction of gendered hierarchies in care work to disrupt the exclusive participation of women in the global labor markets as care workers.
This study assesses the impacts of the COVID-19 pandemic on healthcare access for Washington State Home Care Aides (HCAs). Analyzing 62 months of medical claims data from over 35,000 HCAs, the research reveals significant healthcare disruptions during the early pandemic, especially in outpatient settings. However, healthcare utilization rebounded swiftly, surpassing pre-COVID levels as new variants emerged. Furthermore, the analysis indicated significant decreases in healthcare utilization for respiratory conditions in later stages of the pandemic, suggesting that the implementation of non-pharmaceutical and pharmaceutical interventions played a crucial role in preventing the transmission of respiratory diseases. Notably, behavioral health-related utilization among HCAs increased significantly throughout most pandemic phases, underscoring the importance of enhancing behavioral health support during public health crises. This research represents the first comprehensive study unveiling the effects of the COVID-19 pandemic on HCAs' healthcare access and opening avenues for further research and policy development to support this essential workforce.
This study, conducted in June and July 2022 through purposive sampling, aimed to explore the relationship between sleep and health performance in 33 pairs of elderly individuals and their migrant caregivers in southern Taiwan. Participants completed a structured questionnaire and wore an Actiwatch for seven days. Pearson correlation and independent t-test were used for analysis. Nearly 50% of foreign home care workers suffered from insomnia, and 80% of elderly care recipients with disabilities experienced sleep disorders. The number of chronic illnesses and/or dementia among the elderly and insomnia among care workers were associated with poor self-perceived health (r = -0.667, p < .001) and sleep disorders among the elderly (r = 0.368, p = .035). The problem of caregiving should be addressed. Future studies should increase the sample size and extend the duration of the study to enhance the generalizability of the findings.
Dementia is a chronic disorder of the brain that affects cognitive performance. The caregivers of individuals with dementia experience a greater burden that affects their Quality of Life (QoL). This cross-sectional study conducted in India was designed to assess the caring burden and QoL among the caregivers of people with dementia, as well as to ascertain the relationship between QoL scores and burden. Our sample included 80 caregivers of people with dementia. Most of the caregivers (n = 59, 73.8%) had a higher level of caregiver burden. There was a negative correlation between caregiver burden scores and QoL. A higher level of caregiver stress and low QoL were experienced by caregivers of dementia patients. In developing countries like India, counseling, and education on home health care for people with dementia should be provided to reduce the burden and enhance the QoL of caregivers.
This study identified the process and agency characteristics associated with poor utilization outcomes - higher percentages of patients (i) admitted to an acute care organization and (ii) visited an emergency room (ER) unplanned without hospitalization - for home health agencies (HHAs) in the United States. We conducted a secondary analysis of data about HHAs' various characteristics, process adherence levels, and utilization outcomes collected from disparate public repositories for 2010-2022. We developed descriptive tree-based models using HHAs' hospital admission or ER visit percentages as response variables. Across the board, hospital admission percentages have steadily improved while ER percentages deteriorated for an extended period. Recently, checking for fall risks and depression was associated with improved outcomes for urban agencies. In general, rural HHAs had worse utilization outcomes than urban HHAs. Targeted investments and improvement initiatives can help rural HHAs close the urban-rural gap in the future.
This study aimed to explore the motivations, attitudes, care management strategies and training needs of paid caregivers. Data were collected through 51 semi-structured interviews with paid caregivers and analyzed using thematic analysis. Their motivations included economic stability, the inability to secure other employment, a desire to secure independence through regularly paid employment and a passion and a love of caring. Their role involved being a key communicator of care between medical personnel and relatives, and participants emphasized the importance of paid caregivers being loving, caring, calm, patient, having the ability and willingness to cope with challenging situations. They outlined some specific challenges of the role of caregiving and expressed the importance of gaining recognition for the role as well as the need for bespoke and tailored training to underpin it. This study adds to the growing international literature around the needs of the paid carer workforce and has the potential to inform policy and training around the provision of a better-equipped workforce to meet the growing needs of the aging population.
The Hospital at Home model, called Hospital-in-Home (HIH) in the Department of Veterans Affairs, delivers coordinated, high-value care aligned with older adult and caregiver preferences. Documenting implementation barriers and corresponding strategies to overcome them can address challenges to widespread adoption. To evaluate HIH implementation barriers and identify strategies to address them, we conducted interviews with 8 HIH staff at 4 hospitals between 2010 and 2013. We utilized qualitative directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR) and mapped identified barriers to possible strategies using the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool. We identified 11 barriers spanning 5 CFIR domains. Three implementation strategies - identifying and preparing champions, conducting educational meetings, and capturing and sharing local knowledge - achieved high expert endorsement for each barrier. A mix of strategies targeting resources, organizational readiness and fit, and leadership engagement should be considered to support the sustainability and spread of HIH.
Critical nursing shortages and experiences of burnout present a significant challenge in the home and community care (HCC) health sector. Determining what factors influence resiliency could inform HCC organizations in developing recruitment and retention resources and strategies. This scoping review identified factors that influence professional resilience in nurses working in the HCC sector. From 1819 documents identified from database searches, using a librarian-informed strategy, eight articles were included. Two domains emerged for HCC nurses, that is, i) professional and work-related characteristics of being resilient; and ii) strategies to promote professional nurse resilience. One domain emerged addressing organizational infrastructure, policy and practices contributing to professional nurse resilience in the HCC sector. The findings revealed that resiliency in HCC nurses extends beyond individual characteristics as nurse professionals, and their personal "self-care" strategies as individual people. Further research is needed to disentangle personal and professional resilience in nurses working in the HCC sector.
Homecare workers face significant occupational risks, necessitating effective safety training programs. This paper presents a comprehensive Train-the-Trainer (TTT) program developed to enhance occupational safety in homecare organizations. Through an analysis of 229 reported safety events, the frequency and type of incidents, such as injuries during handling, road crashes, slips, trips, and falls, were identified and primarily attributed to human errors and violations. Based on the results, a TTT program was designed and implemented. The TTT successfully engaged Health, Safety, and Environment managers, fostering collaborative activities, knowledge sharing, and resource discussions. The program modules address critical areas, including distractions and inattentions, fatigue, time pressure, frustration and aggressiveness, and safety behaviors. This innovative approach provides valuable insights for organizations seeking to improve homecare workers' safety. The findings add to the broader comprehension of occupational safety in the homecare sector, proposing a pragmatic framework for future interventions.
The primary purpose of this study was to explore the needs and challenges of African American family caregivers of People living with dementia (PLWD) from the perspective of service providers including healthcare and social service providers. The study conducted three online semi-structured focus group interviews with service providers (n = 15). Data were analyzed using Braun & Clarke's guide to thematic analysis approach. Five themes emerged from the analysis of the focus group data: (i) Inadequate information about resources; (ii) Dementia education; (iii) Burden of dementia on families; (iv) Limited financial support and funding; and (v) Suggestions for needed resources. Service providers expressed the lack of community-based dementia service and support programs in African American communities. Findings from the study indicated the need to provide culturally appropriate information on dementia caregiving. This study adds to the scope of knowledge by exploring the processes of seeking help and using services.
Medicaid funding for home- and community-based services (HCBS) has increased substantially in recent decades. Prior research has investigated the effects of this expansion on outcomes for individuals as well as costs to Medicaid, often using state policy as a proxy for access to HCBS or implicitly assuming that more generous policies affect outcomes through access, an assumption that may not hold. In this study, using survey data linked to Medicaid claims, we assess the extent to which common measures of state Medicaid HCBS generosity correspond to increased individual use of HCBS among older adults with potential needs. We find several measures to have strong predictive power, but only with relatively large changes in policy generosity. Our findings imply that increased funding of HCBS is not sufficient to ensure access to services and that researchers should be careful when using state policy generosity as a proxy for access.
Rigorous assessments to better understand the person-environment interaction are essential to comprehend how neurocognitive disorders influence in-home functioning of older people living with dementia. No recent synthesis identifies validated instruments targeting the human (e.g. caregivers) and nonhuman (e.g. objects) elements of the home environment interacting with this population and used with the perspective of aging in place. Consequently, following Arksey and O'Malley's (2005) scoping review method, 2,182 articles were identified in six databases and in gray literature. Two reviewers independently selected 23 relevant articles describing 19 validated assessment tools targeting elements of the home interacting with older people with dementia, namely: nonhuman environment (n = 13), human environment (n = 3), and person-environment interaction (n = 3). This overview highlights the scarcity of tools addressing the human environment and the person-environment interaction to foster sustainable at-home living for older people with neurocognitive disorders, demonstrating the need to incorporate new evidence-based, holistic methods into dementia home care.
In Taiwan, the Integrated Home Care (IHC) project was introduced for medically compromised patients living at home receiving Home Health Care (HHC) in 2016. The focus of the project was on organizing care teams and managing care for patients. The aim of this study was to investigate the benefits and impacts of IHC in Taiwan. The primary outcome measure was the mortality rate of patients who received IHC versus those who did not receive IHC (non-IHC). The secondary outcomes were medical utilization and expenditure. The results showed that IHC was associated with a statistically significant reduction in mortality compared to non-IHC for home-dwelling patients over 90-, 180-, and 365-days periods. Additionally, IHC users were less likely to be hospitalized and had shorter hospitalization times compared to non-IHC users. Furthermore, IHC was found to reduce medical expenditure compared to non-IHC.
