Disability Trends Among Community-Dwelling Older Adults and Related Determinants of Disability

Abstract The growing aging population with disabilities poses challenges to caregiving and health care services but there is little recent data on disability trends. Some studies have shown that disability is decreasing while others have shown it increasing. Understanding these trends among community-dwelling older adults is critical for communities to allocate resources and develop policies. This study updates disability trend data among community-dwelling older adults using nationally representative National Health & Aging Trends Study data. Results revealed that about 30% of Medicare beneficiaries had at least one limitation of the activity of daily living (ADL) from 2011 to 2019. Age 75-79 (IRR=1.55), 80-84 (IRR= to 4.60), 85-89 (IRR=2.99), 90+ (IRR=4.60), female, (IRR=1.18), not a house owner (IRR=1.51), financial strain (IRR=1.71), and receiving Medicaid (IRR=1.84) are associated with a higher likelihood of becoming ADL limited or having more ADL limitations. We will discuss potential policy, intervention, and research implications.


OPPORTUNITIES TO IMPACT DISABILITY: TRENDS, COSTS, AND EVIDENCE-BASED INTERVENTIONS Chair: Sarah Szanton Discussant: David Grabowski
As healthcare shifts to a focus on social determinants and population health, and older adults increasingly seek to "age in community," it is vital to understand the functional capabilities and related costs for older adults with disability. This symposium will present data on five major areas related to older adult disability. The 1st presenter will describe recent national disability trends. The 2nd will present Medicare costs by disability, dementia, and community-dwelling status in order to illustrate how these different demographic groups vary in Medicare expenditures over time. This information is critical to policymakers and health systems leaders to plan for these populations. They will then describe a 3rd project, which employs a novel longitudinal modeling approach, Group Based Trajectory Modeling, to identify and describe the distinct trajectories of Emergency Department use after incident disability. This work assesses the heterogeneity in health care use after disability, which may be shaped by available supports. The 4th presentation will describe a combined analysis of the 11 sites that have published data from implementations of the CAPABLE program. This program is a 10 session, home-based interprofessional program that provides an occupational therapist, a nurse, and a handyworker to addresses older adults' self-identified functional goals by enhancing individual capacity and the home environment. Taken together, these presentations can inform interventions and policies that improve the health and quality of life of older adults with disabilities. Interventions to reduce disability are crucial for older adults with disabilities to avert unnecessary hospitalizations or nursing home placements and improve daily life. Developed and tested at one research site, multiple health systems and community based organizations have since implemented CAPABLE. All published or peer reviewed tests of CAPABLE were reviewed (six studies, 11 sites) with a total of 1087 low-income community-dwelling older adults with disabilities. Participants were an average age of 74-79, cognitively intact, and self-reported difficulty with one or more activities of daily living (ADL). These trials were reviewed by extracting the participants' scores on main outcomes, ADLs and IADLs, and when available, fall efficacy, depression, pain and cost savings. All studies yielded improvements in ADL and IADL limitations, with small to strong effect sizes. Studies with the complete dose of CAPABLE showed more improvement in ADLs and cost savings than the studies that implemented a decreased dose.

MEDICARE COSTS BY DISABILITY AND COMMUNITY-DWELLING STATUS Claire Ankuda, and Katherine Ornstein, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Understanding population-level Medicare expenditure patterns for older adults with functional disability is critical to focus supports to reduce costly and potentially burdensome health care use. We used the National Health and Aging Trends Study (NHATS) to assess quarterly Medicare expenditures over the 12 months following NHATS interview. We examine Medicare expenditure patterns for older adults in nursing homes (N=386), in the community and without disability (N=20,103), with disability and dementia (N=2,008), and with disability but not dementia (N=2,945).
One-year mortality ranged from 2.0% for those without disability in the community to 25.9% for those residing in nursing homes. Among those surviving 1 year, Medicare expenditures the first quarter after NHATS survey ranged from $1,794 (95% CI $1,690-$1,898) for those with no disability to $5,177 (95% CI $4,535-$5,818) for those with disability and dementia. We assess trends over the following two years, and find that trajectories vary by clinical grouping. The growing aging population with disabilities poses challenges to caregiving and health care services but there is little recent data on disability trends. Some studies have shown that disability is decreasing while others have shown it increasing. Understanding these trends among communitydwelling older adults is critical for communities to allocate resources and develop policies. This study updates disability trend data among community-dwelling older adults using nationally representative National Health & Aging Trends Study data. Results revealed that about 30% of Medicare beneficiaries had at least one limitation of the activity of daily Innovation in Aging, 2021, Vol. 5, No. S1 living (ADL) from 2011 to 2019. Age 75-79 (IRR=1.55), 80-84 (IRR= to 4.60), 85-89 (IRR=2.99), 90+ (IRR=4.60), female, (IRR=1.18), not a house owner (IRR=1.51), financial strain (IRR=1.71), and receiving Medicaid (IRR=1.84) are associated with a higher likelihood of becoming ADL limited or having more ADL limitations. We will discuss potential policy, intervention, and research implications.

TRAJECTORIES OF EMERGENCY DEPARTMENT USE AFTER INCIDENT FUNCTIONAL DISABILITY Katherine Ornstein, and Claire Ankuda, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Emergency department (ED) visits for older adults with functional disability may represent unmet needs and are often burdensome to patients and families. While it is known that older adults with functional disability use the ED at high rates, this does not capture the heterogeneity of experience after the onset of disability. Using NHATS, we identified a cohort of older adults with incident disability, or who reported they began to receive help with self-care and/or mobility in the prior year. Using the month that they report first receiving help, we linked to Medicare data to assess quarterly patterns of ED use. We used Group Based Trajectory Modeling to assess the trajectories of ED use after disability. We identified three distinct trajectories of ED use: persistently high, declining, and persistently low. We describe the clinical, household, and sociodemographic characteristics associated with likely membership in each trajectory group.

PROVIDING SPECIALTY TELEHEALTH CARE TO OLDER, RURAL PATIENTS: VOICES FROM FIELD Chair: Eileen Dryden Co-Chair: Lauren Moo
Older, rural adults have limited access to quality geriatric specialty care for several reasons including relatively few geriatric specialists in rural areas and lack of transportation options or patient ability to travel to more urban centers. GRECC Connect is a promising telehealth-hub and spoke model that provides rural patients access to teams of multidisciplinary geriatric specialists in more urban medical centers primarily by video connection with affiliated communitybased outpatient clinics (CBOCs). This model provides a viable option for increasing access to geriatric specialty care for rural patients but is not used to the extent it could be. To date, much of our understanding of this model has come from the experts at the hub medical centers. To learn more about the experience of this model from the field we interviewed CBOC staff and providers as well as Veterans and their caregivers about geriatric specialty telehealth services. In this symposium we will discuss facilitators and barriers to implementing this model from the perspective of the field and then explore more deeply both the context of the CBOC environment and the older patient population served by rural CBOCs to further understand the challenges that are faced in attempting to connect older patients with telehealth services. Finally, we will share the perceived value of the service and alignment with local needs. This deeper understanding of the experience of the 'spoke' may help enhance access to much needed geriatric specialty care for rural veterans.

QUALITATIVE EVALUATION: GRECC CONNECT AS A METHOD OF DELIVERING HEALTH CARE TO RURAL OLDER VETERANS
Lauren Moo, 1 William Hung, 2 Eileen Dryden, 3 Camilla Pimentel, 4 Laura Kernan, 3 and Kathryn Nearing, 5 1. VA Bedford Health Care System,Bedford,Massachusetts,United States,2. Veterans Health Administration,New York City,New York,United States,3. Veterans Health Administration,Bedford,Massachusetts,United States,4. VA Bedford Healthcare System,Bedford,Massachusetts,United States,5. Veterans Health Administration,Denver,Colorado,United States The VA Office of Rural Health-funded GRECC Connect program uses telehealth modalities to provide geriatric specialty care to rural older veterans and education to clinicians in VA Community-based outpatient clinics (CBOCs). Qualitative evaluation of GRECC Connect has included interviews with three stakeholder groups: geriatrics specialty teams at 15 hub medical centers, rural CBOC staff, and patients/family caregivers. CBOC staff interviews included 50 individuals from 13 different CBOCs. Staff roles included clinic managers, social workers, psychologists, physicians, nurses, and telehealth technicians. Older veterans who had recently been involved in a GRECC Connect video visit were also invited to share their views on the visit. By including multiple perspectives on the program, we are better positioned to increase reach, access, and improve care for older rural veterans.

THE INTEGRAL ROLE OF CBOCS IN RURAL HEALTHCARE: PROMISES AND CHALLENGES
Camilla Pimentel, 1 Kathryn Nearing, 2 Laura Kernan, 3 Eileen Dryden, 3 and Lauren Moo, 4 1. VA Bedford Healthcare System,Bedford,Massachusetts,United States,2. Veterans Health Administration,Denver,Colorado,United States,3. Veterans Health Administration,Bedford,Massachusetts,United States,4. VA Bedford Health Care System,Bedford,Massachusetts,United States Community-based outpatient clinics are critical to extending the geographic reach of VA's healthcare delivery system. Nationwide, 733 CBOCs provide outpatient care to nearly half of the VA's patient population. The 13 rural CBOCs in the study sample provide outpatient primary care, mental health care, and a limited number of specialty care services. Located 1-3.5 hours away from their closest VA Medical Center, these CBOCs have a wide-sometimes interstate-service catchment area. To effectively serve increasingly older and medically complex patient populations, they rely heavily on partnerships with larger VA Medical Centers and local community providers for inpatient, residential, and additional outpatient services. CBOCs experience myriad staffing challenges, including staff turnover, "access providers" working at multiple CBOCs, and highly variable training in rural health and geriatrics. While some CBOCs have robust telehealth offerings, others cannot currently grow their telehealth capacity owing to constraints in clinic space and provider schedules.