Project Summary Roughly 80% of persons living permanently in US nursing homes have a diagnosis of Alzheimer’s disease and related dementias (ADRD). They often experience avoidable hospitalizations, adverse process-of-care outcomes, and aggressive care of minimal benefit at end-of-life. Additionally, the Coronavirus disease 2019 (COVID-19) pandemic added an unprecedented challenge to providing long-term care. One of the most significant initiatives designed to improve nursing home long-term care quality has been the institutional special needs plan (I-SNP), a specialized Medicare Advantage plan for long-term care residents authorized under the 2003 Medicare Modernization Act. Not only does capitated payment to I-SNPs reduce incentives to hospitalize residents, but the plans are adopt care models designed to increase coordination between the plan and the nursing home to improve primary care. We estimate that both the number of I-SNP plans and enrollees have more than doubled since 2012, and that 7% of all long-term nursing home residents with ADRD were enrolled in an I-SNP as of 2018. The overall objectives of this study are to assess the impact of I-SNP enrollment on long-term care quality for nursing home residents with ADRD both during the pre- and post-pandemic periods, understand factors contributing to I-SNP enrollment and growth, and characterize how I-SNP care practices influence resident outcomes. Our central hypothesis is that I-SNP enrollees with ADRD experience fewer hospitalizations and better care quality than enrollees in traditional fee-for-service Medicare or other MA plans due to comprehensive care management. To test these hypotheses and accomplish our objectives, we propose a mixed-methods study. The quantitative component involves quasi-experimental econometric analyses on a retrospective cohort of long-stay nursing home residents with ADRD using Medicare claims, electronic health record, and other administrative data. The qualitative analysis will obtain key insights from nursing home leaders on I-SNP performance, facilitators, and barriers. This project will produce a comprehensive, nationally representative portrait of I-SNP effectiveness in serving persons with ADRD residing in U.S. nursing homes. Findings will allow residents, families, nursing homes and other providers to make informed decisions about I-SNP enrollment and participation.

Project Narrative The proposed study aligns closely with several strategies under Goal 2 of the National Plan to Address Alzheimer’s Disease. Knowledge gained from this work can be used to help “optimize care quality and efficiency” for persons with ADRD. By producing knowledge that will inform nursing home structure planning and policy decisions, we hope to strengthen the capacity of nursing homes to deliver care which “maintains the dignity, safety, and rights of people with ADRD”.