PROJECT SUMMARY Recent socio-economic and natural disasters, including Hurricane Maria, have exacerbated the exodus of Puerto Rican residents to the US mainland and has led to a “historic net migration loss.” Worse living conditions, ineligibility to low-income subsidies, high poverty rates and limited access to health services may be important drivers for older adults to migrate from Puerto Rico to the US mainland, particularly among those with chronic illness, and complex health care needs. People with Alzheimer’s Disease and Related Dementias (ADRD) have high health care spending, poor outcomes, often require long-term services and supports. The Medicaid program in Puerto Rico does not cover long-term care, which may compel older adults with ADRD to seek long-term care outside of Puerto Rico. However, little is known about drivers of migration and outcomes following migration among Puerto Rican older adults with and without ADRD. Thus, there is a crucial need to understand the aging experience across the life-course, migration patterns and outcomes among older adults from Puerto Rico. Using data for Medicare patients ages 65 and older (since 2010) with rich clinical and socioeconomic variables that allow us to track migration patterns, mortality, utilization of long-term services and supports, our specific aims are as follows: AIM 1) Estimate migration rates and identify drivers of migration among Puerto Rican Medicare beneficiaries with and without a diagnosis of ADRD. Our working hypotheses are that out-migration rates will be higher among older adults following an ADRD diagnosis compared to those without an ADRD diagnosis (H1); Hurricane Maria will have exacerbated out-migration of preexisting ADRD patients relative to the pre-disaster period (H2); People who migrated will be more likely to be black, have lower income, greater social support and higher rates of health care utilization compared to persons who do not migrate, and the effect of these factors will be greater among migrants with preexisting ADRD diagnosis (H3); and AIM2) Examine whether migration moderates the effect of ADRD on mortality, morbidity and hospitalizations among beneficiaries from Puerto Rico. Our working hypotheses are that migration will moderate the effect of ADRD on health decline, mortality and hospitalizations and that these declines will be higher among people with preexisting ADRD diagnosis (H1); migrants with preexisting ADRD will have higher rates of dual eligibility, healthcare expenditures and utilization compared to persons with preexisting ADRD who did not migrate (H2). This proposal is a direct response to the FOA (PAR-21-080) “Addressing the Etiology of Health Disparities and Health Advantages Among Immigrant Populations.” Results from this research could guide interventions 1) to assist older adults residing in Puerto Rico who may want to continue aging at home, so they do not have to migrate; 2) to target any gaps in service delivery that new migrants with ADRD and/or complex chronic conditions may face after arriving to the US; and 3) to restructure Medicare and Medicaid benefits and funding in Puerto Rico; and 4) to provide incentives to increase specialized care in Puerto Rico.

PROJECT NARRATIVE Medicare beneficiaries and vulnerable adults face challenges in accessing specialty care resulting in disparate quality of care and outcomes. Additionally, the Medicaid program in Puerto Rico does not cover long-term services and supports, which may compel older adults with Alzheimer’s Disease and Related Dementias to seek long-term care outside of Puerto Rico. In this study, we will examine migration patterns and determinants of migration, as well as the moderating effects of migration and outcomes following migration among Puerto Rican older adults with and without a diagnosis of Alzheimer’s Disease and Related Dementias.