Culture Change Initiatives in High Medicaid Nursing Homes: Does Time of Adoption Make a Difference?

Abstract Racial/ethnic disparities have been well documented in long-term care literature. As the population ages and becomes more diverse over time, it is essential to identify mechanisms that may eliminate or mitigate racial/ethnic disparities. Culture change is a movement to transition nursing homes to more home-like environments. The literature on culture change initiatives and quality has been mixed, with little to no literature on the use of culture change initiatives in high Medicaid nursing homes and quality. The purpose of this study was to examine how the involvement of culture change initiatives among high Medicaid facilities was associated with nursing home quality. The study relied on both survey and secondary nursing home data for the years 2017-2018. The sample included high Medicaid (85% or higher) nursing homes. The outcome of interest was the overall nursing home star rating obtained from the Nursing Home Compare Five-Star Quality Rating System. The primary independent variable of interest was the years of involvement in culture change initiatives among nursing homes, which was obtained from the nursing home administrator survey. The final model consisted of an ordinal logistic regression with state-level fixed effects. High-Medicaid nursing homes with six or more years in culture change initiatives had higher odds of having a higher star rating, while facilities with one year or less had significantly lower odds of having a higher star rating. Culture change initiatives may require some time to effectively implement, but these initiatives are potential mechanisms to improve quality in high Medicaid nursing homes.


THE RELATIONSHIP BETWEEN DEMENTIA, RACE, AND SCHIZOPHRENIA LABELING IN NURSING HOMES FOLLOWING THE CMS PARTNERSHIP
Shekinah Fashaw, 1 Theresa Shireman, 1 Ellen McCreedy, 1 and Julie Bynum, 2 1. Brown University, Providence,Rhode Island,United States,2. University of Michigan,Ann Arbor,Michigan,United States Preliminary research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents subsequent to the Centers for Medicare & Medicaid Services (CMS) National Partnership to Improve Dementia Care. Given known health disparities and higher antipsychotic use for Black NH residents, we examined how race and dementia influence the rate of schizophrenia diagnoses among NH residents. Using a quasi-experimental study design, we examined changes in schizophrenia reporting among long-stay NH residents' quarterly and/or yearly Minimum Data Set 3.0 assessments between 2011-2015. Employing a difference-in-difference analysis adjusting for independent variables (e.g. demographics, diabetes, heart conditions, and functional status), we examined the relationship before and after the partnership. There were over 4 million MDS assessments annually. Schizophrenia reporting increased 12.3% in the dementia group as compared to 9.3% in the non-dementia group (p<0.0001). Black residents had a significantly higher likelihood of schizophrenia reporting (4%, p<0.0001). After controlling for covariates, there was a 16.5% increase in schizophrenia reporting for Blacks with dementia and 14.9% increase for non-Blacks with dementia (p<0.0001). There were no racial disparities identified among the non-dementia group after controlling for covariates. NH residents were more likely to have schizophrenia documented on their MDS assessments, and following the partnership, schizophrenia reporting rates increased faster for Blacks with dementia than their non-Black peers and their peers without dementia. Further work is needed to determine if schizophrenia diagnoses are appropriately employed in NH practice, particularly for Black Americans and persons with dementia. Racial/ethnic disparities have been well documented in long-term care literature. As the population ages and becomes more diverse over time, it is essential to identify mechanisms that may eliminate or mitigate racial/ethnic disparities. Culture change is a movement to transition nursing homes to more home-like environments. The literature on culture change initiatives and quality has been mixed, with little to no literature on the use of culture change initiatives in high Medicaid nursing homes and quality. The purpose of this study was to examine how the involvement of culture change initiatives among high Medicaid facilities was associated with nursing home quality. The study relied on both survey and secondary nursing home data for the years 2017-2018. The sample included high Medicaid (85% or higher) nursing homes. The outcome of interest was the overall nursing home star rating obtained from the Nursing Home Compare Five-Star Quality Rating System. The primary independent variable of interest was the years of involvement in culture change initiatives among nursing homes, which was obtained from the nursing home administrator survey. The final model consisted of an ordinal logistic regression with state-level fixed effects. High-Medicaid nursing homes with six or more years in culture change initiatives had higher odds of having a higher star rating, while facilities with one year or less had significantly lower odds of having a higher star rating. Culture change initiatives may require some time to effectively implement, but these initiatives are potential mechanisms to improve quality in high Medicaid nursing homes.

IMPLICATIONS OF EXCEEDING THE AGE AND INTERVENTIONS TO EXTEND LIFE PURPOSE: PERSPECTIVES FROM ASIAN CENTENARIANS
Ad Maulod, Normala Manap, Sasha Rouse, and Angelique WM Chan, Duke-NUS Medical School, Singapore, Singapore Centenarians have often been regarded as living paradigms of exceptional longevity yet little is known from their perspective about the purpose, meaning and quality of living longer lives. In Singapore, the number of centenarians has multiplied 30-fold from 50 in 1990 to about 1500 in 2020. Although centenarians are respected as 'national treasures'having witnessed Singapore's transformation from British colony to global city state, their needs remain invisible in both the healthcare and social sectors. The tendency to romanticize exceptional longevity neglects a deeper understanding of (i) its consequence on the oldest old (85+ years) who may be impacted by severe functional and sensory deficits and (ii) their experience of social isolation in the family and communities. This paper discusses findings based on interviews with 15 Singapore centenarians (100 to 111 years old) and their family carers. Diverse experiences of longevity are shaped by these factors: health status; personal disposition; strength of family and social networks; exposure to adversity and coping resources; spiritual beliefs; role loss; and changes in the lived environment. Appropriate health and psychosocial interventions could have been delivered earlier in the life trajectory to enable better quality of life and continued social engagement. Learning from the challenges (eg. social withdrawal; extensive functional and sensory losses) of existing centenarians contributes to a more precise understanding of how best to harness the productive capacities of our oldest old.

SENSE OF COMMUNITY AND QUALITY OF LIFE FOR OLDER ADULTS IN PUERTO RICO 2 YEARS AFTER HURRICANE MARIA Tommy Buckley, Denise Burnette, Humberto Fabelo, and Mauricio Yabar, Virginia Commonwealth University, Richmond, Virginia, United States
Psychological sense of community plays an important role in the wellbeing of older adults, especially in cultures that revolve around community involvement and support. In 2017, Hurricane Maria devastated Puerto Rico, deeply altering community structure and social life. This study draws on the Ecological Theory of Aging to test the proposition that older adults' sense of community is associated with self-assessed quality of life two years later. We conducted face-to-face interviews with a non-probability sample of 154 community-dwelling adults aged 60+ in Puerto Rico. We measured sense of community with the Brief Sense of Community Scale (BSCS) (range 0-32, mean= 24.75, SD= 6.04) and quality of life (QOL) with the EUROHIS-QOL 8-item index (range 0-32, mean= 21.61, SD=5.92). We used multiple linear regression to test the association of sense of community and quality of life while controlling for relevant covariates. Higher levels of sense of community were associated with better quality of life (β=0.270, p<0.001), while increased mental health symptoms (β=-0.557, p<0.001) and poor self-rated health (β=2.964, SE=7.17, p<0.001) were associated with lower quality of life. Findings indicate that sense of community is an important contributor to older adult's quality of life in Puerto Rico, perhaps in part due to cultural and age-related factors. Moreover, sense of community may serve as a protective factor against adverse outcomes after large scale natural disasters. Researchers should continue to examine this association while advocating for and developing policies and programs that promote older adults' sense of community in post-disaster contexts.

THEY DO THEIR BEST, BUT THEIR BEST ISN'T GOOD ENOUGH: HOW SOCIAL HOUSING CAN SUPPORT OLDER TENANTS AGING IN PLACE
Christine Sheppard, 1 Andrea Austen, 2 and Sander Hitzig, 3 1. Sunnybrook Research Institute,Toronto,Ontario,Canada,2. City of Toronto,Toronto,Ontario,Canada,3. Sunnybrook Hospital,North York,Ontario,Canada Toronto Community Housing (TCH) is the second largest social housing landlord in North America, and is home to over 27,000 older adults, half of whom live in 83 "seniorsdesignated" buildings. There is inadequate and inconsistent delivery of services in these buildings, negatively impacting tenants' ability to age in place. We conducted two half-day consultations with service providers (n=74) and tenants (n=100) to identify strategies to improve unit condition, promote stable tenancies (i.e., prevent evictions) and enhance access to health and support services for older adults living in TCH. Through facilitated discussion, participants identified their top two recommendations for each priority area and reflected on the strategies that were hardest and easiest to implement, as well as the ones that would have the most and least impact on quality of life for older tenants. Participants recognized the need for more education as a way to empower older tenants and reduce stigma associated with unit condition issues (e.g., pest problems) and arrears. More frequent touch points with tenants was also recommended as a way to identify older adults at-risk of eviction and work proactively (instead of reactively) to support them. Service providers and tenants believed that system navigators working directly in the buildings would be a key facilitator to building trust and helping older tenants access needed services. Outcomes of the have several program and policy implications for TCH, as they partner with the City of Toronto to design a new integrated service model for the seniors-designated buildings.

WHICH SEAT AT THE TABLE? THE WAYS THAT SENIOR SERVICE ORGANIZATIONS ARE ENGAGED IN AGE-FRIENDLY COMMUNITY EFFORTS Caitlin Coyle, and Shayna Gleason, University of Massachusetts Boston, Boston, Massachusetts, United States
Senior centers across the nation continue to serve as important access and focal points for older adults to voice their desires, get basic needs met, and to engage in opportunities Innovation in Aging, 2020, Vol. 4, No. S1