Research Area: Caring for Aging Populations and Persons with Disabilities

Healthcare organizations play a key role in addressing the complex needs of aging populations and persons with disabilities, which comprise a significant proportion of the U.S. population. According to the 2020 U.S. Census, 1 in 6 people were age 65 and over with this number expected to grow to nearly 1 in 4 by 2040. The CDC estimates that more than 1 in 4 adults have some type of disability. AMGA works with member organizations to develop measures and implement interventions to support value-based care for this population of aging persons and those with disabilities.

Care for people living with Alzheimer’s Disease and related dementias 

• Implementation of MIND at Home for People Living with Dementia: AMGA was awarded a National Institute on Aging IMbedded Pragmatic Alzheimer’s Disease and Related Dementias Clinical Trials (IMPACT) pilot grant. The study, Implementation of MIND at Home Program in Primary Care for People Living with Dementia, sought to embed and test the feasibility of a novel home-based care coordination approach, MIND at Home, a program developed by Johns Hopkins University Medical Center, within primary care. Comprehensive social, environmental, and medical needs assessments were completed with the patient and caregiver to identify and address unmet needs. Two key learnings from the implementation process were (1) trust is a key factor in program recruitment and (2) primary care providers were reluctant to put dementia diagnoses in the electronic health record due to concerns of patient and family acceptance. Complete findings coming soon! Learn More

Homebound and other vulnerable populations

• Home-Based Medical Care Utilization among Medicare Advantage Cohort: AMGA conducted a database study that defined a cohort of Medicare Advantage (MA) patients who received home-based medical care (HBMC) and compared to those not receiving HBMC. MA beneficiaries who received HBMC were older, experienced greater chronic and serious illness burden, and had higher levels of facility-based care than those who did not receive HBMC, suggesting MA plans might seek strategies to identify patients in need of HBMC. Learn More

Palliative care and serious illness

• Identification of People with Serious Medication Conditions (SMCs) for Palliative Care: Clear operational definitions of this population that can benefit from palliative care do not exist. AMGA reviewed de-identified claims and EHR data to identify this population, and ultimately found it was feasible to identify this group in a commercially insured population, including Medicare advantage enrollees. Separate use of EHR or claims resulted in population differences such that only 50% of people identified as having SMCs were recognized by both data sources. People with SMCs were identified among 10% and 9% of those aged ≥18 in claims and EHR data, respectively; however, only 50% of people identified as having SMCs were identified by both data sources. Future research should consider combining data sources to support population management, quality measurement, and interventions to improve care for those living with serious illness. Learn More