Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Johns Hopkins School of Nursing, Baltimore, Maryland, USA.
J Gerontol B Psychol Sci Soc Sci. 2022 Dec 29;77(12):e216-e225. doi: 10.1093/geronb/gbac072.
Community-living older Medicare and Medicaid enrollees ("dual-enrollees") have high care needs and commonly receive paid and unpaid long-term services and supports (LTSS) to help with routine activities. Little is known about whether receiving paid help or individuals' state and neighborhood environmental context ("LTSS environment") relates to dual-enrollees' care experiences.
We examine a sample of n = 979 community-dwelling dual-enrollees with disabilities from 2011 to 2015 National Health and Aging Trends Study, linked to measures of neighborhood disadvantage and state Medicaid home and community-based services (HCBS) generosity. Logistic regression models stratified by dementia status assess associations between paid help and: (a) adverse consequences due to unmet care needs, and (b) participation restrictions in valued activities, among dual-enrollees with and without dementia, adjusting for individual and LTSS environmental characteristics.
Use of paid help was greater for those with (versus without) dementia (46.9% vs. 37.8%). Neighborhood disadvantage was associated with greater use of paid help among dual-enrollees living with dementia. High state Medicaid HCBS generosity was associated with the use of paid help, regardless of dementia status. Dual-enrollees with dementia receiving paid help had higher odds of experiencing adverse consequences due to unmet need (adjusted odds ratio = 2.05; 95% confidence interval 1.16-3.61; p = .02)-no significant associations were observed for participation restrictions. Use of paid help and LTSS environment were not significantly associated with care experiences for dual-enrollees without dementia.
Findings highlight the complexities of caring for dual-enrollees, particularly those with dementia, and emphasize the need to strengthen the delivery of paid care with considerations for the LTSS environment.
居住在社区的 Medicare 和 Medicaid 双重参保老年人（“双重参保者”）有较高的护理需求，通常需要接受有偿和无偿的长期服务和支持（LTSS），以帮助其进行日常活动。对于接受有偿帮助以及个人所在州和社区环境（“LTSS 环境”）是否与双重参保者的护理体验相关，目前知之甚少。
我们使用 2011 年至 2015 年国家健康老龄化趋势研究中 n = 979 名有残疾的社区居住的双重参保者样本，这些样本与衡量邻里不利因素和州 Medicaid 家庭和社区为基础的服务（HCBS）慷慨程度的措施相关联。使用逻辑回归模型，按痴呆状态分层，评估在有和没有痴呆的双重参保者中，有偿帮助与以下方面的关联：（a）因未满足的护理需求而产生的不良后果；以及（b）在考虑个体和 LTSS 环境特征的情况下，对有价值活动的参与受限。
与没有痴呆的双重参保者相比（37.8%），有痴呆的双重参保者更倾向于使用有偿帮助（46.9%）。对于居住在有痴呆的双重参保者，邻里不利因素与有偿帮助的使用增加相关。高州 Medicaid HCBS 慷慨程度与有偿帮助的使用相关，而与痴呆状态无关。接受有偿帮助的有痴呆的双重参保者经历因未满足的需求而产生不良后果的可能性更高（调整后的优势比=2.05；95%置信区间 1.16-3.61；p =.02），但对于参与受限则没有观察到显著关联。对于没有痴呆的双重参保者，有偿帮助的使用和 LTSS 环境与护理体验没有显著关联。
研究结果突出了照顾双重参保者，尤其是照顾痴呆症患者的复杂性，并强调需要在考虑 LTSS 环境的情况下，加强有偿护理的提供。
