Practically Speaking
Winter 2023

Another Look Grantees 2022

This fall, the Donaghue Foundation added four awards to its Another Look–Research to Improve Health for Older Adults in Long-Term Care Facilities program with an investment totaling nearly $1.2 million for this year’s cycle. Since the beginning of the program in 2013, the Another Look grant program has awarded over 5.5 million dollars in funding for research that has the near-term potential to improve the health of older adults in long-term care facilities.

Michael L Barnett, M.D., M.S.

Michael L Barnett, MD, MS
Harvard T.H. Chan School of Public Health
Stakeholder Organization: American Medical Directors Association (AMDA) – The Society for Post-Acute and Long-Term Care Medicine
“Understanding Specialty Care Delivery for High-Need Nursing Home Residents with Serious Mental Illness and Development Disabilities”

Specialty care is an essential component of care delivery for patients with complex illnesses including appropriately managing medications for conditions like schizophrenia or other serious mental illness. Patients with serious mental illness and developmental disabilities often face barriers to accessing specialty care despite having high needs. Little is known about specialist care use once such patients, often with declining mobility and deteriorating health, move from living in the community to a nursing home for long-term care. Many factors, including lack of personnel or family support, or difficulties in organizing transportation, can make it difficult to get to a specialty appointment. To bridge this evidence gap, this project will use national Medicare claims to investigate specialist care before and after patients with serious mental illness and developmental disabilities move to a skilled nursing facility (SNF), or nursing home. They will compare the patterns observed to patients with other conditions and those in the community. They will also assess for variation in specialty care use across the patient, facility, or regional characteristics and how patterns changed during the COVID-19 pandemic, and the effect of telemedicine. This project will deliver the first national estimates of specialty care use in nursing homes and therefore guide policy solutions to reduce disparities in specialty access.

Howard B. Degenholtz, PhD

Howard B. Degenholtz, PhD
University of Pittsburgh
Stakeholder Organization: Pennsylvania Department of Human Services, Office of Long-Term Living
“The Effect of Medicaid Managed Care on Quality of Behavioral

The study will examine the effect of Medicaid Managed Long-Term Services and Supports (MLTSS) on the quality of behavioral health for nursing home residents with Alzheimer’s Disease and Related Dementias (ADRD) and Serious Mental Illness (SMI). The prevalence of nursing home residents with SMI (i.e., major depression, bipolar disorder, or schizophrenia) has been increasing; this hurts quality and compounds racial and ethnic disparities. This has a disproportionate impact on racial and ethnic minorities, who are more likely to live in nursing homes with lower levels of staffing and poor quality of care. Long-standing concerns over the appropriate use of psychotropic medications and the under-use of non-pharmacologic treatments are linked to challenges inherent in the current system of payment that creates silos and disincentives coordination across Medicaid and Medicare. In 2018, Pennsylvania began a three-year phased implementation of MLTSS to improve the coordination of long-term services and supports, medical care, and behavioral health care. In conjunction with this change, PA explicitly required coordination between medical and behavioral health services for nursing home residents. The phased implementation will facilitate causal estimates of the effect of coordinated care on 1) guideline-concordant prescribing of psychotropics and other mental health services, 2) depressive symptoms and behavioral symptoms that affect other residents and staff, and 3) changes in racial and ethnic disparities in the use and quality of behavioral health. Findings will support state policymakers seeking to improve this population’s access to and quality of behavioral health care.

Alisha H. Johnson, PhD., RN

Alisha H. Johnson, PhD, RN
University of Missouri
“Describing advanced practice nurses’ influence on improved nursing home outcomes”

Advanced practice registered nurses (APRN) improve resident outcomes in nursing homes, but the full description of how they influence these outcomes is little understood. They propose to answer two research questions: 1) How does the practice of full-time, embedded APRNs in the nursing home (NH) influence outcomes through altered NH structures and processes? and 2) What full-time embedded APRN direct and indirect care activities influence the NHs’ response to the COVID-19 pandemic? They will use data collected from 8 years (2012-2020) of the Missouri Quality Initiative project, which achieved its goal of reducing resident hospitalizations by employing full-time APRNs working on-site in 16 nursing homes in the St. Louis, Missouri area. In collaboration with their community stakeholder VOYCE, the long-term care ombudsman for the St. Louis area, they will compare high versus low-performing nursing homes to better understand how APRN practice activities change nursing home operations to deliver better resident care. To understand how APRNs influenced nursing home response to the COVID-19 pandemic, they will use Missouri Quality Initiative project data from the first 8 months of the pandemic to describe APRN practices that were beneficial during the emergency pandemic response. Study findings will be valuable to stakeholders interested in effective systems of care for nursing home residents, including administrators, advocacy groups, and educators. Findings will be shared via training and care conferences hosted by their community stakeholder.

Jeffrey E. Stokes, PhD., and Danielle Waldron, PhD

Jeffrey E. Stokes, PhD, and Danielle Waldron, PhD
University of Massachusetts Boston
Stakeholder Organization: The Arc of Massachusetts
“Loneliness, Living Arrangements, and Health among Older Adults with Developmental Disabilities in Long-Term Care”

Adults with intellectual and developmental disabilities (I/DD) encounter disparities in many facets of their healthcare compared to the general population, despite presenting more frequently with numerous medical conditions, such as mental illness, pain and distress, dental disease, and functional decline (Watson et al., 2020; Tinglin, 2013). Moreover, the needs of and challenges faced by individuals aging with I/DD are not uniform, and additional factors likely intersect with I/DD status to mitigate or exacerbate health and health services utilization (HSU) disparities. The purpose of this project is 1) to examine intersectional factors – particularly living arrangements – that may explain health and HSU disparities within the population of adults aging with I/DD receiving state services, 2) to examine health and HSU disparities between the population of older adults with and without I/DD, and 3) to examine change in these areas from 2008-2019. They also plan to explore the roles of social isolation and loneliness in the health and HSU of adults with I/DD, given that adults with disabilities experience greater isolation and loneliness than their non-disabled peers (Emerson et al., 2021). The conceptual framework for this work is the National Institute on Aging’s Health Disparities Framework for priority populations, which assesses environmental, sociocultural, behavioral, and biological factors. Taken together, the results of this project will inform practitioners, policymakers, and researchers engaged in reducing health and health utilization disparities among the population aging with I/DD, a population that remains poorly understood even as it will continue to grow in the coming years.