Kali S. Thomas, Ph.D. - US grants

DESCRIPTION (provided by applicant): There is a fundamental gap in our knowledge of the over 710,000 older adults residing daily in the 22,000+ assisted living (AL) facilities in the US. This is primarily due to our inability to identify AL residents with secondary data as we have for beneficiaries receiving services in nursing homes (NHs). The long-term goal of this research agenda is to study the changing landscape of long-term care (LTC) and to understand the role of AL in providing quality care to our nation's most at-risk elders in much the same manner previously done with NHs. Critical impediments to this goal is the lack of a national dataset of ALs, a methodology to identify and track AL residents' LTC trajectories, and an understanding of how changes in the AL market affects other LTC sectors. To address this problem, our main goals of this application include the collection of an updated national census of AL providers to validate a methodology for identifying AL residents using secondary data sources. The rationale that underlies this proposed re` search is that a national dataset of AL providers, a validated method to identify AL residents, and an understanding of the effect of the growth in the national AL market will, for the first time, allow researchers to investigate in more detail the national landscape of AL utilization and resident outcomes. The specific aims include: 1) To compile, geocode, match to other LTC data, and make publicly available a 2013 national dataset of AL providers on LTCfocUS.org, 2) To test the validity of a methodology for identifying AL residents against samples of Medicare beneficiaries receiving healthcare services within an AL and 3) To evaluate the effect of changes in the geographic supply of AL beds between 2007 and 2013 on the private-pay NH market. Our research is innovative because we will be the first to supply a national dataset of ALs and we put forward a new and unique approach to identify AL residents, namely the use of the 9-digit ZIP code reported in Medicare enrollment records, which we will validate by combining Home Health assessment data and Medicare Part B Place of Service Codes. In addition, we will improve our ability to identify the relationship of changing AL supply with the market for NH care by creating an innovative measure that captures the number of private-pay resident days in NHs on a national scale. Consequently, a better understanding of the effect of the changing AL market on NH private-pay occupancy and length of stay is expected to result. This work is significant because as more private, State, and Federal dollars are spent on AL, identifying users of these services, tracking their healthcare utilization and outcomes, and understanding the impact on other LTC market sectors becomes crucial. In addition, findings from this research have the strong potential for providing us the fist step in a continuum of research to be proposed in an R01 grant application following the completion of this work that is expected to elucidate provider quality, AL resident outcomes (e.g. hospitalization and NH placement), racial and ethnic disparities, and healthcare costs associated with this large, growing site of LTC.

PROJECT SUMMARY/ABSTRACT Approximately one million individuals, an estimated 40-72% with cognitive impairment or a diagnosis of Alzheimer?s disease-related dementias (ADRD), reside in assisted living (AL); yet, little is known about their experience or the quality of care offered. Unlike other forms of long-term care (LTC), such as nursing homes that are federally regulated, the licensing, operating, and enforcement requirements for AL falls to the states, which vary dramatically in their approaches to regulating this growing industry. As AL assumes an increased role in providing LTC to vulnerable older adults with ADRD, there is an urgent need to understand the positive and negative effects of state regulations on quality of care. Our long-term goal is to improve care outcomes for AL residents, with a specific emphasis on residents with ADRD who often cannot advocate for themselves. The overall objective of this application is to examine states? AL regulatory environments and understand if and how the health outcomes of AL residents with ADRD are impacted by states? regulatory decisions. The central hypothesis is that in order to survive, AL providers adhere to licensing requirements and respond to changes in the regulatory environment, which ultimately impact AL residents? outcomes. The rationale for the proposed research is that better understanding the experiences of AL residents with ADRD and how they vary based on a state?s approach to regulating this industry will help to inform policy and payment decisions and ultimately improve the outcomes of older adults with ADRD needing LTC. Guided by strong preliminary data, this hypothesis will be tested by pursuing three specific aims: 1) Characterize how states regulate AL as it relates to the care of residents with ADRD; 2) Test the effect of regulations on providers? responses and outcomes of AL residents with ADRD; 3) Compare outcomes between residents with ADRD who reside in ALs licensed to provide specialized dementia care to residents in non-specialized ALs. Under the first aim, investigators will build on their previous efforts to identify and examine the history, oversight, and enforcement of states? AL regulations likely to impact outcomes of residents with ADRD. In the second aim, investigators will apply a novel methodology they developed through an R21 from the National Institute on Aging (#R21AG047303) to identify AL residents using Medicare data and with rigorous methods examine the effect of regulatory changes on providers? behaviors and residents? outcomes over a 10-year period. Under the third aim, investigators will apply an observational, quasi-experimental methodology to examine the effect of living in a dementia- specialized AL on residents? outcomes. This approach is innovative because it is the first to examine the outcomes of AL residents with ADRD, nationally, and the impact of the widely varying AL regulations on healthcare outcomes. The proposed research is significant because it will provide valuable information to states as they seek the most effective ways to regulate this growing industry. Ultimately, such information has the potential to improve the outcomes of vulnerable older adults with ADRD who utilize AL.

SUMMARY There is little information available on the predictors of long-term outcomes of older patients with traumatic brain injury (TBI). Without this information, clinical decision-making and discharge planning will continue to be limited, thereby preventing ideal patient-centered, cost-effective, and appropriate care for older patients with TBI. The objective of this application is to merge multiple sources of valuable data to examine predictors of meaningful outcomes, particularly functional and cognitive improvement and the ability to return home following post-acute (PAC) rehabilitative care, among older patients age 65+ years with TBI. The rationale that underlies this proposed research is that an understanding of predictors of improvement in physical and cognitive function, PAC therapies provided to patients, and subsequent healthcare utilization and outcomes could impact care for older patients with TBI. Guided by an experienced interdisciplinary team with statistical and clinical expertise, this proposal has two specific aims: 1) To create a national longitudinal database that follows older patients with TBI across multiple healthcare settings and 2) To identify patient characteristics that predict community discharge and functional improvement during the PAC rehabilitative episode. Under the first aim, the team will use deterministic and probabilistic matching to merge data from the National Trauma Data Bank, the largest aggregation of national trauma registry data, with Medicare claims, the Minimum Data Set (MDS), and the IRF Patient Assessment Instrument (IRF-PAI). This is innovative because it will identify and retrospectively follow a national cohort of older patients with TBI from hospital admission through PAC discharge and include rich data on their injury characteristics, health, and function. Under the second aim, the team will identify the health and contextual factors that are associated with older patients? functional improvement and ability to return to the community following rehabilitation. The contribution of this work will be significant because it will provide patients, family members, providers, and healthcare systems with strong evidence needed to provide high quality TBI care for older patients at a reasonable cost. The expected benefit of this research is evidence that will: 1) enable clinicians to better understand the recovery trajectory and potential outcomes for older patients with TBI; 2) inform organization of care and rehabilitation services; 3) assist family members in setting expectations; 4) promote informed discharge planning; and 5) ultimately, enhance the health, independence, and quality-of-life of older adults with TBI. In addition, this work provides the first step in a continuum of research to be proposed in future R01 grant applications that is expected to elucidate the comparative effectiveness of different types and intensities of PAC therapies, other longer-term health outcomes (e.g., community independence) and healthcare utilization (e.g., hospital readmission, hospice care, home health) for patients with TBI.

PROJECT SUMMARY Older adults with a diagnosis of Alzheimer?s disease and/or a related dementias (ADRD) are at increased risk of food insecurity. There is a strong, documented link between food insecurity and health. However, less is known about how home-delivered meals, designed to reduce food insecurity, enable older adults with ADRD to remain in their homes (vs moving to a nursing home). While meals have traditionally been provided daily to clients? homes by a volunteer or paid driver who visits with the client and reports any concerns about the client to the meal provider, less frequent deliveries of frozen meals have emerged in recent years as a lower-cost alternative. In this model, participants are provided two weeks? worth of meals in one bulk delivery via postal courier. Our R61 is a pilot pragmatic randomized controlled trial that compares the outcomes between these two common approaches for delivering meals to food insecure persons with ADRD. In order to generate preliminary evidence of efficacy to justify scaling up this pilot study to a Phase III trial, this administrative supplement seeks to expand the sample size from a feasibility study of 10 individuals at two Meals on Wheels programs to a pilot of 235 participants at three programs. In addition, we propose to incorporate two additional data sources to analyze from our prior work that, when combined, will give us the power needed to determine preliminary efficacy of the interventions. The research conducted during the R61 will not only test and validate procedures to recruit individuals with ADRD on Meals on Wheels waiting lists and evaluate their outcomes, but will also be the first to prospectively evaluate the time to nursing home placement among older adults with ADRD who receive the two predominant meal delivery options. The knowledge generated from this research will set the stage for a larger, Phase III trial that will evaluate the effectiveness of receiving daily home- delivered meals and accompanying wellness check and socialization versus frozen, mailed meals on the time to nursing home placement (primary outcome) as well as days in community and hospital transfers (secondary outcomes) among 2000+ food insecure older adults with ADRD; and 2) characterize differences in the context, processes, and mechanisms contributing to the outcomes observed between the two modes of meal delivery among older adults with ADRD. Ultimately, the knowledge generated from this line of research will help healthcare entities, senior nutrition programs, persons with ADRD, and their families choose between the meal delivery model that best meets the nutrition-related needs of persons with ADRD and prevents nursing home placement.