ADULT DAY SERVICES IN A RURAL REGION: CHALLENGES AND OPPORTUNITIES

Abstract Adult day services (ADS) programs provide stimulation and socialization for older adults with cognitive and physical disabilities, and much needed respite for family caregivers. Like many services for older adults, ADS programs are far less available in rural regions of the country than in more urban settings. This paper reports on a needs assessment for an ADS program in a small city, which serves as a health and human services hub for a large rural area; a particular focus of the study was to assess the feasibility and interest in intergenerational programming. Family caregivers were surveyed (n = 84) about their use and knowledge of and interest in ADS. Less than one in five respondents were using or had ever used ADS. Cost (20%) and ignorance of such programs (20%) were primary reasons for not using ADS; reduction of stress was the most frequently cited reason for using ADS (73%). Ten in-person interviews were conducted with ADS program directors and service providers who refer clients to ADS. Funding issues emerged as the key challenge given lack of private insurance coverage and poor reimbursement levels from public insurance programs. Challenges around transportation, stigma, and marketing of services also surfaced in the interviews. Nonetheless, all ten informants spoke of the positive impact of ADS for both consumers and their caregivers, and generally endorsed intergenerational activities, though with caveats. Implications will be discussed, including the need for greater financial support for this valuable aspect of our long-term supports and services system.


MORE THAN JUST A ROOM: RESULTS FROM AN INTERGENERATIONAL HOME SHARING PROGRAM IN TORONTO
Raza M. Mirza, 1 Laura Martinez, 1 Andrea Austen, 1 Lynn McDonald, 1 Christopher Klinger, 1 Jessica Hsieh, 1 and Tonya Salomons 1 , 1. National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada Older adults prefer to live in their own homes for as long as possible -to 'age in place' -but for myriad reasons may be unable to do so. To address this, a number of housing alternatives have been explored, including homesharing, or homeshare, an exchange-based shared housing approach with the potential to empower older adults to age in place by enabling them to obtain additional income, companionship, and assistance with completing household tasks in exchange for renting out a room in their home. An intergenerational homesharing pilot program was launched in Toronto, matching older adults (55+) with postsecondary students. With limited research in the area, a mixed methods research study was embedded within the pilot project with the goals of: 1) conducting a scoping review to map and synthesize the literature related to outcomes of homeshare participation for this population, 2) conducting in-depth interviews with homeshare participants (N=22) to learn about their experiences, and 3) conduct a full evaluation and exit survey to better understand the implications of the project. Results were organized around the following themes: (1) benefits and challenges of participating in homeshare for older adults; (2) intergenerational engagement as social exchange; and (3) the key role of agency facilitation as a determinant of the experience of homesharing for older adults. Results spoke to the unique benefits and challenges of participating in homeshare for this population. Findings were used to derive implications for policy and practice, as well as highlight areas for future research.

HOME CARE NURSES CLAIM MEDICARE IGNORES SOCIAL DETERMINANTS OF HEALTH William D. Cabin 1 , 1. Temple University, Philadelphia, Pennsylvania, United States
There is significant literature on the importance of addressing social determinants of health (SDOH) in order to improve health care outcomes. In response, the Centers for Medicare and Medicaid Services (CMS) has expanded Medicare Advantage plans ability to cover SDOH-related services. Medicare home health does not cover SDOHrelated services. A literature review indicates no studies on the nature, significance, or impacts of the lack of SDOH coverage in Medicare home health. The current study is an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 37 home care nurses between January 2013 and May 2014 in the New York City metropolitan area. Results indicate nurses believe the lack of SDOH coverage in Medicare home health results in exacerbation of existing patient conditions; creation of new, additional patient conditions; increased home care readmissions and re-hospitalizations; increased caregiver burden; and exacerbation of patients' mental health and substance abuse needs. Adult day services (ADS) programs provide stimulation and socialization for older adults with cognitive and physical disabilities, and much needed respite for family caregivers. Like many services for older adults, ADS programs are far less available in rural regions of the country than in more urban settings. This paper reports on a needs assessment for an ADS program in a small city, which serves as a health and human services hub for a large rural area; a particular focus of the study was to assess the feasibility and interest in intergenerational programming. Family caregivers were surveyed (n = 84) about their use and knowledge of and interest in ADS. Less than one in five respondents were using or had ever used ADS. Cost (20%) and ignorance of such programs (20%) were primary reasons for not using ADS; reduction of stress was the most frequently cited reason for using ADS (73%). Ten in-person interviews were conducted with ADS program directors and service providers who refer clients to ADS. Funding issues emerged as the key challenge given lack of private insurance coverage and poor reimbursement levels from public insurance programs. Challenges around transportation, stigma, and marketing of services also surfaced in the interviews. Nonetheless, all ten informants spoke of the positive impact of ADS for both consumers and their caregivers, and generally endorsed intergenerational activities, though with caveats. Implications will be discussed, including the need for greater financial support for this valuable aspect of our long-term supports and services system. Ongoing concerns about the quality of care provided to nursing home (NH) residents have led the federal government to develop quality measures (QMs) for NHs. Many of these QMs are included in the NH 5-star ratings and reported online via Nursing Home Compare. However, we know little about how NH providers view the QMs, challenges they experience in addressing the measures, and strategies they use to achieve better scores. As part of a broader mixed-methods study to understand how NHs are responding to the 5-star ratings, we conducted interviews with NH personnel (n=110) and observed organizational processes in 12 NHs in three states. We also interviewed policy and industry leaders (n=34) to gain their perspectives. Interviews focused on perceptions of the 5-star ratings, organizational strategies to improve 5-star scores, experiences with the survey/regulatory process, and perceptions and responses to individual QMs. Key themes show that a) NH providers view the QMs as important indicators of quality, but there is variability across indicators; b) providers face challenges related to measurement and definitions for certain QMs (e.g., pain, restraints); and c) there are potentially conflicting goals, where some QMs aim to promote safety at the expense of resident autonomy and quality of life and vice versa. This work provides organizational context to the 5-star measures and the balancing act providers engage in to assess and improve their scores. The findings also identify several potentially unintended consequences related to the QMs, which can adversely affect residents, particularly those with more complex care needs.

THE ROLE OF POLICY CONTEXT IN INDIVIDUAL LONG-TERM CARE DECISIONS IN OECD COUNTRIES Selena Caldera 1 , 1. LBJ School of Public Affairs -University of Texas at Austin, Austin, Texas, United States
While family caregiving of the elderly has long been part of the cultural life of most OECD countries, longer life expectancy combined with low fertility rates has increased the share of the population dependent on current workers and minimized the available population of informal caregivers. The demand for expanded public provision of long-term care (LTC) resulting from this demographic shift prompted reforms in many OECD countries in the 1990s and 2000s. Differences in these reforms provide an opportunity to examine how individual choices between formal and informal care types are shaped by the policy context. I use longitudinal data on elders in three OECD countries, Sweden, Germany, and Japan, to examine LTC decisions under three varied approaches to population aging. The direction of LTC reforms in each country has been shaped by the existing model of care provision and financial constraints. In response to cost pressures, Sweden introduced need-based provision, financial devolution, and market-based approaches to its universal care model. Germany and Japan, in contrast, widely expanded restricted LTC coverage through public LTC insurance models. I use three multinomial logistic models of the LTC decision to test how differing policy schemes influence choices between formal and informal care. Using longitudinal Global Gateway to Aging data for each country, I model the LTC decision in each country as a factor of demographic and need characteristics of the elder experiencing limitations, characteristics of their family, and eligibility for publicly-provided LTC.

LOOKING UPSTREAM: THE ASSOCIATION BETWEEN AFFORDABLE HOUSING, NURSING HOME USE, AND UNMET CARE NEEDS IN THE COMMUNITY
Meghan Jenkins Morales, 1 and Stephanie Robert 1 , 1.

University of Wisconsin-Madison, Madison, Wisconsin, United States
In the U.S., population aging is coinciding with a growing affordable housing crisis. Evidence suggests that housing security contributes to health, but less is known about how affordable housing affects aging in place. We use a nationally representative sample (n=5,117) of older communitydwelling Medicare beneficiaries from the 2015 National Health and Aging Trends Study to test the association between housing cost burden (HCB) and moving to a nursing home, death, or remaining in the community by 2017. Among 2017 community-stayers (n=4,836), we also test the association between HCB and unmet care need, defined as experiencing a consequence related to 12 mobility (e.g., stayed in bed), self-care (e.g., skipped meals) and household (e.g., no clean laundry) activities. HCB is the proportion of income spent on rent or mortgage: low (<30%), moderate (30-50%), severe (≥50%), or home paid off (referent). Among nursing home movers, 26% had moderate or severe HCB in 2015 compared to 16% of community-stayers. Informed by the person-environment fit perspective, weighted stepwise regression models (multinomial and logistic) adjust for race, age, sex (Model 1), self-rated health, probable dementia (Model 2), living with others and high income (Model 3).