Many older adults living in rural communities have limited access to resources that promote health. Yet, little is known about the factors contributing to disparities in access to specific resources. Therefore, this study identified sociodemographic predictors of gaps in access to five resources (transportation, social support, food security, healthcare, and safe housing) among rural older adults (N = 795). Data was collected as part of an evaluation of the Rural Aging Action Network (RAAN) - a national collaborative that mobilizes existing and recruits new community-based services and supports. Multivariate logistic regressions examined sociodemographic predictors of gaps in resource access among RAAN users. Income-restricted older adults were twice as likely to have gaps in safe housing (95% CI [1.16, 4.78]), transportation (95% CI [1.11, 4.09]), or healthcare (95% CI [1.20, 4.25]), over three times more likely to have a food security gap (95% CI [1.44, 7.39]), and almost four times as likely to have a social support gap (95% CI [1.85, 8.37]) compared to those with adequate income. Older adults of color were over twice as likely to have a transportation gap (95% CI [1.12, 6.14]) and over three times as likely to have a food security gap (95% CI [1.30, 8.28]) compared to Whites. Veterans were over twice as likely to have a housing gap (95% CI, [1.04, 6.57]), yet 81% less likely to have a social support gap (95% CI [0.04, 0.88]) compared to non-veterans. Study findings can help providers identify rural older adults with greatest service needs.

Under the Biden Administration, registered apprenticeships emerged as a promising strategy for healthcare providers to recruit, train, and retain a qualified workforce, supported by expanded access to federal and state funding. Yet, nursing homes and other aging services providers have been slow to adopt this model, often facing barriers related to regulatory complexity, limited infrastructure and resources, and lack of tailored guidance. This paper describes how the federally funded Geriatrics Workforce Enhancement Program (GWEP) is working to close this gap by supporting the development of registered apprenticeship programs for direct care professionals in long-term care settings. First, we outline the structure and distinguishing features of registered apprenticeships and describe how GWEP grantees are helping introduce and adapt this model within nursing homes. Second, we present the formation and early activities of a national GWEP learning network convened by the Moving Forward Nursing Home Quality Coalition and focused on developing common standards and best practices for apprenticeship implementation for nursing home certified nursing assistants (CNAs). Drawing on stakeholder input and early field experiences, we highlight considerations related to program design, partnership building, and alignment with quality improvement and other organizational goals. Finally, we discuss the broader policy and regulatory implications of expanding apprenticeships in the long-term care workforce and offer recommendations to support their sustainable growth.

Volunteers of America National Services’ (VOANS) Aging with Options (AWO) program - funded by and developed in partnership with Parker Health Group - is designed to support wellness and improve chronic disease management for residents in affordable senior housing. The intervention, piloted at one housing site, provided in addition to an existing service coordinator, a wellness nurse and a community health worker to help engage residents in healthy behaviors and connect them with resources. The evaluation effort assessed participants’ perceptions of the program’s impact by implementing a resident survey (N = 69); and determined the program’s effect on health outcomes by analyzing service- and health-related data collected regularly by program staff (N = 99). Over 94% of AWO participants reported that the supports received from AWO program staff were helpful. The most frequently mentioned program benefits were an improved sense of health, enhanced well-being and safety, and greater social connection. Residents who developed a wellness plan - for which they identified health and wellness goals and steps to achieve these goals - reported experiencing positive changes such as eating healthier food, greater success controlling health conditions, and exercising more. Regression analyses conducted to identify service-related predictors of health outcomes six months after the program’s initiation showed that higher life optimism was associated with receiving more service instances of ‘follow-up with service providers.’ Further, better self-rated physical health was associated with receiving more service instances of ‘exercise/physical fitness’, ‘socialization’, and ‘encouragement to attend event/program.’” Evaluation findings underscore the program’s benefits for resident health and well-being.

The Gateway-In Project© (TGIP©) was established to expand the CNA and HHA workforce by recruiting students, providing free training, supports, and job placement assistance for new CNAs and HHAs in California. To assess TGIP©’s impact, we surveyed Year 1 graduates for employment status and career plans 12-18 months post-graduation. We also surveyed Year 2 students before (baseline) and after training completion to determine changes in students’ views of working in aging services, their financial and employment status. Students of both cohorts were mostly women of color, 35 years or younger, and had low household incomes. Over 80% of Year 1 students (N = 271), were employed as CNAs, HHAs, or both with close to 70% working in skilled nursing facilities. Working as a CNA/HHA was predominantly (74%) perceived as “a steppingstone to furthering their career” over “a career” or “job to make money.” Most students (73%) reported planning to advance to another occupation, particularly to a higher nursing degree/occupation. Year 2 students (N = 146) showed significantly lower interest in working as a CNA/HHA (t=-4.923, p=.004) and in working with older adults (t=-2.78, p=.006) after training completion compared to baseline. There was a significant increase in household income (t = 2.140, p=.034). Most were employed as CNAs. TGIP© evaluation demonstrates employment gains, important career advancement aspirations, and increased household incomes. Decreases in interest in working as CNAs/HHAs and with older adults may be due to the job’s demands becoming clearer during training. The ongoing evaluation efforts will provide further insights into TGIP©’s long-term impact.

This symposium aligns with the Social Research, Policy, and Practice Section’s focus on social, economic, and environmental contexts of aging by examining the role of arts-based interventions in fostering social connectedness among historically marginalized individuals and communities. Convened by Goddard House, a non-profit provider of assisted living and memory care which also offers creative aging programs in underserved neighborhoods throughout Greater Boston, this session will contribute to ongoing discourse on the implementation and evaluation of community-engaged interventions that enhance quality of life for older adults. Candace Cramer, MA, MBA, CEO of Goddard House, will moderate the symposium and provide an overview of Goddard House’s philosophy of creative aging programs. Katherine Richman, PhD, and Caitlin Coyle, PhD, will summarize evaluation findings of MusicWorks, a program offered at affordable senior housing sites in Boston that fosters community through music that resonates with a culturally and economically diverse group of older adults. Eileen Tell, MPH, and Jacob Watson, EdM, will provide a summary of their comprehensive literature review and environmental scan—the first since 2015—highlighting the evidence base on the effectiveness of creative engagement strategies in reducing social isolation and loneliness. This summary, in conjunction with the findings of the MusicWorks evaluation, demonstrates new and promising approaches to reduce social isolation and loneliness among older adults. Robyn Stone, DrPH, will serve as a discussant, providing a critical analysis of how community-based participatory arts programs can inform broader policy and practice to enhance the well-being of older adults who face systemic barriers to social inclusion.

Introduction:The behavioral health (BH) needs of older adults are unique, increasing, and, too often, poorly understood. Methods:Oregon established the first state-level center of excellence in the United States focused on the BH of older adults via a state-university-community partnership. Oregon's Center of Excellence for Behavioral Health and Aging (OCEBHA) was conceptualized by the state health authority and initially funded using a block grant from the Substance Abuse and Mental Health Services Administration. Results:OCEBHA seeks to expand the capacity of health and social programs and providers to deliver BH services for older adults with serious mental illness and substance use disorders through translational research, workforce development, and policy innovation. Conclusion:This review article describes the United States' and Oregon's BH and aging landscape, highlighting the disconnects between research evidence, clinical treatment/intervention, and policy implementation. It outlines the rationale for establishing centers like OCEBHA, which was designed to bridge these gaps. By detailing OCEBHA's structure and focus areas-translational research, workforce development, and policy innovation-the article shows how this model can help align evidence-based practices with service delivery and policy. It also offers a roadmap for other states seeking to strengthen support for older adults with BH needs.

More than 4 million older Americans with cognitive impairment (CI) live alone. These individuals often face unique challenges due to limited or non-existent support from caregivers. Identifying the barriers and facilitators to accessing long-term services and supports (LTSS) is critical to preventing the adverse outcomes to which this population is particularly vulnerable, including self-neglect, untreated medical conditions, medication mismanagement, falls, and fires. This qualitative study, conducted between May 2016-February 2024, included adults aged 55+ from diverse racial and ethnic backgrounds who were living alone with CI in California, Louisiana, and Michigan, as well as members of their social circle. Factors influencing LTSS access were identified via in-person, semi-structured interviews conducted in English, Spanish, Cantonese, or Mandarin. Transcripts were analyzed with combined inductive and deductive content analysis drawing from the micro-meso-macro framework. A total of 119 older adults living alone with cognitive impairment (88 [71.5%] women; median age, 78 years [range, 57-103]) and 56 members of their social circle (45 [80.3%] women; median age, 45 years [range, 39-89]) were interviewed multiple times for a total of 558 interviews. Barriers to accessing LTSS included: healthcare providers being unhelpful, distrustful, dismissive, and unaffordable, with rigid protocols and long waiting periods; cognitive impairment itself in the context of living alone; limited resources. having chronic medical conditions; “hunting” for services; information from attentive healthcare providers; support with transportation. Findings underscore the importance of ensuring that critical LTSS are tailored around the needs of older adults living alone with CI.

Fallon Health, a managed care organization offering the Senior Care Options (SCO) program in Massachusetts, received a grant from the Executive Office of Health and Human Services to assess and improve supportive services in affordable senior housing in a rural part of the state. Partnering with Acumen and LeadingAge, the team conducted an evaluation of 11 properties through resident surveys (N = 327) and focus groups with property managers (N = 6) and resident service coordinators (RSCs) (N = 5). Findings revealed that most properties have operated for over 20 years and lack infrastructure suited for aging residents. Common health conditions include hypertension and arthritis, with half of residents at risk for depression and a quarter for loneliness. Social engagement is moderate. Residents most often require housekeeping and transportation assistance. While nearly all properties employ RSCs, their on-site presence is limited to adequately address resident needs. Other key challenges include RSC staffing, inconsistent assessments, and a lack of community-based service providers with whom to partner. Recommendations include increasing RSC presence, conducting periodic needs assessments to address resident needs, and strengthening community partnerships to coordinate service delivery, care integration and transportation. Massachusetts should explore using targeted Medicaid and state funds to build RSC capacity, incentivize health and social service providers to team with housing organizations and expand telehealth services. The Fallon Health Navigator program, embedded in these sites, should be strengthened and serve as a model for other SCOs. The solutions could improve the well-being of affordable housing residents and support their ability to age in place.

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have worsened; regulations have become complex; the need for consumer support, education, and advocacy has grown; and financing and accessibility have become insufficient. Together, these factors have limited the extent to which today's assisted living adequately provides assistance and promotes living, with negative consequences for aging in place and well-being. This Commentary provides recommendations in four areas to help assisted living meet its promise: workforce; regulations and government; consumer needs and roles; and financing and accessibility. Policies that may be helpful include those that would increase staffing and boost wages and training; establish staffing standards with appropriate skill mix; promulgate state regulations that enable greater use of third-party services; encourage uniform data reporting; provide funds supporting family involvement; make community disclosure statements more accessible; and offer owners and operators incentives to facilitate access for consumers with fewer resources. Attention to these and other recommendations may help assisted living live up to its name.

How to build a new foundation for a new generation. In 1978, fresh out of a master's program in aging policy, I came to Washington, D. C., to work for the American Association of Retired Persons/ National Retired Teachers Association. It was an exciting time for aging advocacy. My organization had a clear mission focused on the development of policies and programs that ensured health and economic well-being for all elderly Americans. A wide range of other national organizations advocated for policies and programs to meet the needs of America's elders. In the Congress, the Senate Aging Committee and the House Select Committee on Aging had committed members and a knowledgeable, zealous group of young staffers who worked with the advocates to expand the aging services network and to strengthen health and retirement policies. The executive branch's Administration on Aging was in its heyday, with a significant discretionary budget to support innovative programs like OnLok in San Francisco, the Triage Case Management Program in Connecticut, and other community-based aging services. The U.S. Department of Health, Education and Welfare (now the Department of Health and Human Services-DHHS) funded a multi-million-dollar research and demonstration initiative-the Channeling Demonstration-to test the efficacy and cost effectiveness of noninstitutional home and community-based care. Twenty-five years later, just as the United States is about to experience the most significant demographic phenomenon in its history-the aging of the baby boomers-advocacy for aging policies and programs at the national level seems to have lost its compass. The Assistant Secretary for Aging in DHHS is little more man a figurehead. As Deputy Assistant Secretary for Disability, Aging and Long-Term Care Policy in the Clinton administration, I struggled to keep aging on the DHHS agenda. The focus was on children, youth, and families; elders were not included. The House Select Committee on Aging is gone. The National Conference of Senior Citizens-the advocacy arm of organized labor-is defunct, the Gray Panthers are rarely heard from, and the Older Women's League, the only organization that advocates specifically for older women, is struggling to survive. AARP (now just the acronym without retired persons in the name) has reinvented itself as an organization representing people over age 50. (I, in fact, started getting my mailings to join AARP when I was 48!) In the following discussion, I identify, then review some of the key issues that must be addressed in reinvigorating aging policy and program advocacy in the twenty-first century. I conclude with some thoughts on how to develop a cadre of advocates to meet the demands of a burgeoning elderly population. WHY HAS ADVOCACY WITHERED? Several factors have contributed to a withering of advocacy for aging policies and programs in the United States. Loss of champions. In the halcyon days of aging advocacy, a number of individuals championed the cause. These included people like Arthur Fleming, the tireless statesman who worked within the governmental system to help create the Administration on Aging, the White House Conferences on Aging, and other venues for supporting aging policies and programs. Claude Pepper, congressman and senator from Florida, consistently supported policies designed to improve the health and long-term care of older people and tried to use his political power and moral persuasion to engage otiier members of Congress. Others worked outside the system. Maggie Kuhn, the gentle lioness who founded the Gray Panthers, was relendess in her advocacy for elders by bringing the generations together. Tish Sommers, a displaced homemaker who post-divorce found herself without adequate resources, developed a grassroots organization that grew into the Older Women's League. These individuals made lifelong commitments to their issues, continuing to advocate for these causes until their deaths. …

Objectives: Describe use of home-based clinical care and home-based long-term services and supports (LTSS) using a nationally representative sample of homebound older Medicare beneficiaries.Setting and Participants: Homebound, community-dwelling fee-for-service Medicare beneficiaries participating in the 2015 National Health and Aging Trends Study (n 1/4 974).Methods: Use of home-based clinical care [ie, home-based medical care, skilled home health services, other home-based care (eg, podiatry)] was identified using Medicare claims. Use of home-based LTSS (ie, assistive devices, home modification, paid care, >40 hours/wk of family caregiving, transportation assistance, senior housing, home-delivered meals) was identified via self or proxy report. Latent class analysis was used to characterize patterns of use of home-based clinical care and LTSS.Results: Approximately 30% of homebound participants received any home-based clinical care and about 80% received any home-based LTSS. Latent class analysis identified 3 distinct patterns of service use: class 1, High Clinical with LTSS (8.9%); class 2, Home Health Only with LTSS (44.5%); and class 3, Low Care and Services (46.6% homebound). Class 1 received extensive home-based clinical care, but their use of LTSS did not meaningfully differ from class 2. Class 3 received little home-based care of any kind.Conclusions and Implications: Although home-based clinical care and LTSS utilization was common among the homebound, no single group received high levels of all care types. Many who likely need and could benefit from such services do not receive home-based support. Additional work focused on better understanding potential barriers to accessing these services and integrating home-based clinical care services with LTSS is needed.& COPY; 2023 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Abstract Bridging research and policy allows research findings to have a lasting impact in the wellbeing of vulnerable population such as the estimated 4.3 million older adults living alone with cognitive impairment in the United States. For example, a lasting impact comes from healthcare and social services provided by Medicare and Medicaid tailored to address unmet needs of these populations identified via rigorous research. Despite the importance of bridging research with policy, researchers seldom collaborate with policy makers, thus missing the opportunity of influencing policies. Reasons for these limited collaborations include limited knowledge on methods for researchers to collaborate with policy makers. This session will draw from the expertise gained by the research team of the 5-year Living Alone with Cognitive Impairment Project to involve policy experts in the design of their mixed-method study. Regular interactions between the research team and the Policy Advisory Group led to: 1) a mixed-method design aligned with policy priorities; 2) a report highlighting the priorities of PAG members with regard to policies to enhance the wellbeing of older adults living alone in the US; 3) a series of policy briefs highlighting key findings and related policy recommendations. The oversight of a Policy Advisory Group allowed the Living Alone with Cognitive Impairment Project to focus research activities that are likely to be translated into policy solutions, thus likely to mostly benefit older adults living alone with cognitive impairment, with emphasis on communities of color. These practices can be replicated by researchers in studies supporting underserved populations.

Background: Low nursing home staffing in the United States is a growing safety concern. Socioeconomic deprivation in the local areas surrounding a nursing home may be a barrier to improving staffing rates but has been poorly studied. Thus, the objective of this paper was to assess the relationship between neighborhood deprivation and nursing home staffing in the United States. Methods: This cross-sectional study used 2018 daily payroll-based staffing records and address data for 12,609 nursing homes in the United States linked with resident assessment data. Our primary exposure of interest was severe economic deprivation at the census block group (neighborhood) level, defined as an area deprivation index score >= 85/100. The primary outcome was hours worked per resident-day among nursing home employees providing direct resident care. Marginal linear regression models and generalized estimating equations with robust sandwich-type standard errors were used to estimate associations between severe neighborhood deprivation and staffing rates. Results: Compared to less deprived neighborhoods, unadjusted staffing rates in facilities located within severely deprived neighborhoods were 38% lower for physical and occupational therapists, 30% lower for registered nurses (RNs), and 5% lower for certified nursing assistants. No disparities in licensed practical nurse (LPN) staffing were observed. In models with state-level and rurality fixed effects and clustered on the county, a similar pattern of disparities was observed. Specifically, RN staffing per 100 resident-days was significantly lower in facilities located within severely deprived neighborhoods as compared to those in less deprived areas (mean difference: 5.6 fewer hours, 95% confidence interval [CI] 4.2-6.9). Disparities of lower magnitude were observed for other clinical disciplines except for LPNs. Conclusions: Significant staffing disparities were observed within facilities located in severely deprived neighborhoods. Targeted interventions, including workforce recruitment and retention efforts, may be needed to improve staffing levels for nursing homes in deprived neighborhoods.

Given the instability of the nursing home (NH) certified nursing assistant (CNA) workforce and the challenging demands during COVID-19, it is important to understand the organizational factors that are correlated with job satisfaction which is a major predictor of CNA turnover. The purpose of this study was to determine the associations between quality of supervisor relationships, organizational supports, COVID-19 work-related stressors, and job satisfaction among CNAs in NHs. The results indicate that CNAs who reported a more optimal relationship with their supervisors, felt appreciated for the job they do and worked in NHs with lower COVID-19 resident infection rates tended to report higher rates of job satisfaction. The COVID-19 work-related stressors of increased workload demands and understaffing were associated with lower rates of job satisfaction. The study has practical implications for employers regarding how to support CNAs to improve job satisfaction especially during a crisis.

IMPORTANCE The potential role of living alone in either facilitating or hampering access to and use of services for older adults with cognitive impairment is largely unknown. Specifically, it is critical to understand directly from health care and social services professionals how living alone creates barriers to the access and use of supportive health care and social services for racially and ethnically diverse patients with cognitive impairment. OBJECTIVE To identify the potential role of living alone in the access and use of health care and social services for diverse patients with cognitive impairment by investigating professionals' perceptions of caring for such patients who live alone in comparison with counterparts living with others. DESIGN, SETTING, AND PARTICIPANTS This qualitative study of 76 clinicians, social workers, and other professionals used semistructured interviews conducted between February 8, 2021, and June 8, 2022, with purposively sampled professionals providing services to diverse patients with cognitive impairment in Michigan, California, and Texas. MAIN OUTCOMES AND MEASURES Clinicians, social workers, and other professionals compared serving patients with cognitive impairment and living alone vs counterparts living with others. An inductive content analysis was used to analyze the interview transcripts. RESULTS A total of 76 professionals were interviewed (mean [SD] age, 49.3 [12.7] years); 59 were female (77.6%), 8 were Black or African American (11%), and 35 were White (46%). Participants included physicians, nurses, social workers, and home-care aides, for a total of 20 professions. Participants elucidated specific factors that made serving older adults living alone with cognitive impairment more challenging than serving counterparts living with others (eg, lacking an advocate, incomplete medical history, requiring difficult interventions), as well as factors associated with increased concerns when caring for older adults living alone with cognitive impairment, such as isolation and a crisis-dominated health care system. Participants also identified reasons for systematic unmet needs of older adults living alone with cognitive impairment for essential health care and social services, including policies limiting access and use to public home-care aides. CONCLUSIONS AND RELEVANCE In this qualitative study of professionals' perspectives, findings suggest that living alone is a social determinant of health among patients with cognitive impairment owing to substantial barriers in access to services. Results raised considerable concerns about safety because the US health care system is not well equipped to address the unique needs of older adults living alone with cognitive impairment.

The potential moderating role of living alone in either facilitating or hampering access to services to older adults with cognitive impairment is largely unknown. Given the estimated 4.3 million older adults from diverse racial/ethnic backgrounds who are living alone with cognitive impairment in the United States, it is critical to understand directly from providers of healthcare and social services whether living alone creates barriers to supportive services for racially/ethnically diverse patients with cognitive impairment. The objective of this study was to identify the potential moderating role of living alone in the use of healthcare and social services for patients with cognitive impairment by eliciting providers’ perceptions of caring for diverse patients with cognitive impairment living alone, in comparison to counterparts living with others. This qualitative study used semi-structured interviews conducted between March 2021 and June 2022 with purposively sampled providers of services to diverse patients with cognitive impairment in Michigan, California, and Texas. An inductive content analysis was used to analyze the data. The majority of the 76 interviewed providers belonged to communities of color and cared for racially/ethnically diverse patients with cognitive impairment. Providers included physicians, nurses, social workers, home care aides, for a total of 20 professions. Providers elucidated specific factors that made serving people living alone with cognitive impairment (PLACI) more challenging, as well as specific factors that increased their concerns when serving PLACI, including a crisis-dominated healthcare system. Providers also elucidated reasons for systematic unmet needs of PLACI for essential healthcare and social services, such as policies limiting access to home-care aides. The vast majority of providers underscored the critical, yet understudied, role of living alone in moderating access to essential healthcare and social services among patients with cognitive impairment. Findings suggest that living arrangement are a social determinant to health among patients with cognitive impairment because patients with cognitive impairment who live alone are more likely to experience gaps in services because they are more challenging to serve than counterparts living with others and the healthcare system is not designed to address these challenges.