The Role of Health, Social Network, and Race in Advance Care Planning Among Medicare Beneficiaries

Abstract Advance care planning (ACP) is linked with high-quality end-of-life outcomes. However, ACP engagement level among older adults varies significantly by demographic, social, and health characteristics. In this study, we sought to identify characteristics associated with informal and formal ACP, in order to inform development of targeted education and outreach efforts that are tailored to diverse groups of older adults. The data came from a nationally representative study of Medicare beneficiaries living in communities, the National Health and Aging Trends Study (Round 8, N= 5,547). Multivariable logistic regressions were conducted to identify individual characteristics (i.e., race/ethnicity, age, gender, income, functional disability, cognitive function, perceived health, and numbers of people in social networks) associated with ACP engagement. Rates of informal ACP (talking to someone), and formal ACP, completing a healthcare power of attorney (HPOA) and a living will (LW), were 56%, 60.5%, and 56% accordingly. Logistic regression showed that individuals who were married or had a larger social network, and had higher functional impairment and health needs were significantly more likely to engage in both informal and formal ACP. However, individuals with memory problems (only informal ACP) and African Americans and Hispanics were significantly less likely to engage in both informal and formal ACP. African Americans without dementia were more likely to have completed HPOA compared with Whites. Findings suggest an important role of social network, and functional and cognitive health in ACP with implications for developing targeted outreach efforts in faith-based or social group settings, and healthcare settings.

was to explore the nature of advance care planning in ESRD. The study utilized mixed methods and both qualitative and quantitative data was collected during in-depth chairside interviews with 31 people while they were on hemodialysis. Participants ranged in age from 29-85; Mage=60; (N=13 [40%/)60). The data was divided above and below the Mage, and distinct differences were found in the nature of advanced care planning by age group. Greater numbers of people >60 (N=11[61%]) were not considering a transplant while (N=9[69%]) of those under 60 had a failed transplant and were again on the waiting list. Although the majority of participants had a health care proxy (N=27[87%]), more who were >60 had a proxy who knew their wishes (N=14[78%]) compared with (N=9[69%]) who were 60 compared with none <60. The qualitative data illuminated these age-differentiated responses in themes: Older age and (1) Multimorbidity; (2) Frequency/intensity of hospitalization; (3) Diminished hope of transplantation; and (4) More acute death awareness. The need for disease-specific advance care planning-with hopes and expectations about transplant--and attention to the influence of age and decline cannot be overstated.

SOCIAL EXCLUSION AND SUICIDAL IDEATION: ANALYSIS OF THE BEREAVED LIVING ALONE
Bomi Choi, Hey Jung Jun, and Sun Ah Lee, Yonsei University, Seoul, Republic of Korea The aim of this study is to explore the relationship between social exclusion and suicidal ideation among bereaved older people living alone. When people with a significant loss in the familial relationship are exposed to social exclusion, they likely experience poor mental health and suicidal ideation. Using the Korean Community Health Survey 2017, logistic regression model was applied to the bereaved older people living alone, 65 to 110 of age (N=14,659). Social exclusion was comprised of three network-based components: exclusion from relationships, social participation, and community. Relationship exclusion means the lack of contact with family, friends, and neighbors, respectively, at least once a week. Social participation exclusion refers to the lack of participation in a religious, socializing, and leisure activity, respectively, at least once a month. Community exclusion covers two indicators of trust in neighbors and perception of neighborhood reciprocity. Results showed that indicators of relationship, social participation, and community exclusion were associated with suicidal ideation. Bereaved, living-alone older people were likely to have suicidal ideation when they lack contact with neighbors (OR=1.13, p<.05), participation in the religious activity (OR=1.12, p<.05) and socializing activity (OR=1.20, p<.05), and trust in neighbors (OR=1.29, p<.001). The moderation analysis showed that exclusion from socializing activity was associated with suicidal ideation only among females. The results of the analyses imply that interventions that promote social participation could improve the mental health of the bereaved older adults living alone. Given population aging and impact of both spousal and social support on the health of older adults, the protective role of social support amongst recently bereaved older adults represents an important area of research. The aim of this study is to identify the relationship between recent widowhood and change in depressive symptoms in older adults, and how social support moderates this association. Utilizing observations from the nationally representative Health and Retirement Study, the analytic sample consisted of 2,890 adults age 50 and over who were partnered or married in 2012. Depression was measured using the Center for Epidemiological Studies Depression scale short form (CESD-8). Positive social support was measured as perceived social support from family, friends, and children. Widowhood was a dichotomous measure indicating mortality of spouse between 2012 and 2014. Autoregressive multiple regression was used to determine if widowhood was associated with change in depression from 2012-2104 and whether positive social support moderated this relationship. Widowhood was associated with an increase in depressive symptoms from 2012-2014 (b=0.967, SE=0.145, p <.001) and social support was negatively associated with change in depression (b=-0.021, SE=0.004, p <.001). Social support appeared to moderate the association between widowhood and change in depression (b=0.068, SE=0.026, p =.010), though widowed older adults with higher social support appear to have more rapid increase in depression than those with lower social support. These preliminary findings and implications for supporting bereaved older adults will be discussed. Advance care planning (ACP) is linked with high-quality end-of-life outcomes. However, ACP engagement level among older adults varies significantly by demographic, social, and health characteristics. In this study, we sought to identify characteristics associated with informal and formal ACP, in order to inform development of targeted education and outreach efforts that are tailored to diverse groups of older adults. The data came from a nationally representative study of Medicare beneficiaries living in communities, the National Health and Aging Trends Study (Round 8, N= 5,547). Multivariable logistic regressions were conducted to identify individual characteristics (i.e., race/ethnicity, age, gender, income, functional disability, cognitive function, perceived health, and numbers of people in social networks) associated with ACP engagement. Rates of informal ACP (talking to someone), and formal ACP, completing a healthcare power of attorney (HPOA) and a living will (LW), were 56%, 60.5%, and 56% accordingly. Logistic regression showed that individuals who were married or had a larger social network, and had higher functional impairment and health needs were significantly more likely to engage in both informal and formal ACP. However, individuals with memory problems (only informal ACP) and African Americans and Hispanics were significantly less likely to engage in both informal and formal ACP. African Americans without dementia were more likely to have completed HPOA compared with Whites. Findings suggest an important role of social network, and functional and cognitive health in ACP with implications for developing targeted outreach efforts in faith-based or social group settings, and healthcare settings. Caregivers have identified consistent visits by professional hospice staff at the end of life as positively affecting experiences of care quality. Little is known about the prevalence of such visits. Using 100% Medicare hospice claims with discharge dates in Federal Fiscal Year 2018, we identified the rates of providing skilled nurse or social worker visits to hospice beneficiaries in at least two of the last three days of life and compared these rates to percentages of caregivers indicating they would "definitely" recommend the hospice and caregivers rating the hospice a 9 or 10 on a 10-scale from CAHPS Hospice scores. Among our analytic cohort of 762,238 hospice discharges, 509,585 individuals (66.9%) were visited by a nurse or social worker in at least two of the last three days of life. Beneficiaries lacking these visits were more likely to be black (black 39.6% vs. white 32.2%; AOR 1.32 95% CI 1.29-1.34) or resided in a nursing facility (nursing facility 37.7% vs. patient's home 32.1%, AOR 1.39 95% CI 1.36-1.40). The mean hospice-level score for achieving these visits was 64.8% (median 70.2%; IQF 53.0%-80.9%). The Pearson's correlation coefficients between hospice-level rates of visits at the end of life and the caregiver percentages for "definitely" recommending the hospice was 0.2418 and for rating the hospice a 9 or 10 on a 10-scale was 0.2587. These findings demonstrate significant variability across hospice providers and signal a positive correlation with caregivers' quality ratings. Future work is needed to monitor the provision of these visits.

VIDEO INTERVENTION TO INCREASE KNOWLEDGE ABOUT AND INTEREST IN PALLIATIVE CARE AMONG MSW STUDENTS Cathy Berkman, Fordham University, New York, New York, United States
As the population ages and more people live longer with chronic and life-limiting illnesses, more healthcare professionals with palliative care skills are needed. Social workers are part of the palliative care team, but there is little, if any, content on palliative and end-of-life care in MSW programs. A 24-minute video featuring nine palliative and hospice social workers was produced with two goals: 1) increase knowledge of social work students about palliative and end-of-life care; and 2) interest social work students in a career in palliative social work. MSW students from three schools, in NY and Alabama, viewed the video. After viewing the video, 94 students participated in the mixed methods study, completing the brief, anonymous, online survey. The mean level of understanding about what palliative social workers do, rated from 1 (no understanding) to 5 (very good understanding), was 2.96 (SD=.99) before viewing the video and 4.31 (SD=.61) after, for an increase of 1.35 points (95% CI=1.14, 1.55) (p<.001). The mean level of interest in a career in palliative care social work and working with seriously ill persons and their family members, rated from 1 (Not at all interested) to 5 (Extremely interested), was 2.52 (SD=.99) before viewing the video and 3.45 SD=.80) after, for an increase of .91 points (95% CI=.79, 1.07) (p<.001). Qualitative data supporting the quantitative findings will be presented. This study suggests that a video intervention may be an effective tool to increase knowledge and interest in palliative and end-of-life care among social work students.

WHAT IS IMPORTANT AT THE END OF LIFE? PERSPECTIVES FROM EXPERIENCED HOME CARE WORKERS
Emma Tsui, 1 Emily Franzosa, 2 and Kathrin Boerner, 3 1. CUNY Graduate School of Public Health & Health Policy,New York,New York,United States,2. James J. Peters VA Medical Center,Bronx,New York,United States,3. University of Massachusetts Boston,Boston,Massachusetts,United States Home care workers (HCWs) make up a large and rapidly growing sector of the American health care workforce serving older adults. This study focuses on a common but understudied feature of home care labor: workers' thoughts around what makes a "good" or "bad" patient death. While researchers have investigated patients', families', physicians', and other care providers' perspectives on this issue, the perspectives of HCWs, who contribute substantially to home-based care at the end of life, have yet to be explored. We conducted 40 in-depth interviews with HCWs in New York City on their experiences with and reflections on patient death. We used a inductive, iterative approach to analyze data on what HCWs believe is important for dying patients. HCWs described EOL values that align well with the views held in common by patients, families, and other care providers, like the importance of not being alone when dying and being physically comfortable (not in pain and not suffering). In particular, HCWs conceptualized a detailed role for themselves when providing EOL care near the time of death. HCWs' sustained presence and relationships with patients may uniquely position them to assist in the attainment of patients' EOL goals, particularly when HCWs understand what these goals are. HCWs' potential for playing this role, however, is jeopardized by a lack of training in EOL care and by the limited information they receive about a patient's health status.

AN EXPLORATION OF LEARNING RESULTS AND CURRICULA GAPS WITHIN AN ONLINE GRANDFAMILIES CERTIFICATE PROGRAM Jennifer Crittenden, University of Maine, Bangor, Maine, United States
Professionals who work with grandparents raising grandchildren have cross-cutting training needs that span content in gerontology, social services, child welfare and program development. To address these needs, a unique, asynchronous, online continuing education program was launched by the UMaine Center on Aging. To-date the program has 177 individual program completers with learners from across the U.S. and Hong Kong that are affiliated with a diverse set of