Receipt of Posthospitalization Care Training Among Medicare Beneficiaries’ Family Caregivers

IMPORTANCE Medicare conditions of participation require hospitals to provide training to family and unpaid caregivers when their support is necessary to enact the postdischarge care plan. However, caregivers often report feeling unprepared for this role. OBJECTIVE To describe the characteristics of caregivers who assist with posthospitalization care transitions and assess the prevalence of and factors associated with receipt of adequate transitional care training. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed data from the 2017 National Health and Aging Trends Study and its linked National Study of Caregiving, surveys of Medicare beneficiaries and their family and unpaid caregivers. The present study included family caregivers for community-living Medicare beneficiaries 65 years or older with disabilities. Data analysis was performed from June to September 2020. MAIN OUTCOMES AND MEASURES Characteristics of family caregivers by whether they assisted during a posthospitalization care transition in the year preceding the survey interview. Unweighted frequencies and weighted percentages, as well as the results of weighted Pearson and Wald tests for differences between groups, are reported. Receipt of the training needed to manage the older adult’s posthospitalization care transition (hereafter referred to as adequate transitional care training) as a function of individual caregiver characteristics was modeled using multivariable, weighted logistic regression. RESULTS Of 1905 family caregivers, 618 (58.9%) were 60 years or older, 1288 (63.8%) were female, and 796 (41.7%) assisted with a posthospitalization care transition. Those who assisted with a posthospitalization care transition were more likely to report experiencing financial (154 [18.3%] vs 123 [10.1%]; P < .001), emotional (344 [41.3%] vs 342 [31.1%]; P < .001), and physical (200 [22.2%] vs 170 [14.6%]; P = .001) difficulty associated with caregiving. Among caregivers who assisted during a posthospitalization care transition, 490 (59.1%) reported receiving adequate transitional care training. Caregivers were less likely to report receiving adequate training if they assisted an older adult who was female (316 [62.3%] vs 227 [73.2%]; P = .02), Black (163 [14.0%] vs 121 [19.8%]; P = .02), or enrolled in Medicaid (127 [21.2%] vs 90 [31.9%]; P = .01). After adjusting for older adult characteristics, caregivers were half as likely to report receiving adequate training if they were Black (adjusted odds ratio [aOR], 0.52; 95% CI, 0.31-0.89) or experienced financial difficulty (aOR, 0.50; 95% CI, 0.31-0.81). Caregivers were more than twice as likely to report receiving adequate training if they were female (aOR, 2.44; 95% CI, 1.65-3.61) or spoke with the older adult’s clinician about his or her care in the past year sometimes or often vs never (aOR, 1.93; 95% CI, 1.19-3.12). CONCLUSIONS AND RELEVANCE In this cross-sectional study, caregivers were less likely to receive adequate transitional care training if they were Black; experienced financial difficulty; or cared for a (continued) Key Points Question Does receipt of adequate training related to managing older adults’ posthospitalization care vary by family caregiver and older adult characteristics? Findings In a cross-sectional study of 1905 caregivers assisting an older adult after hospital discharge, 59.1% reported receiving the training that they needed. Caregivers were less likely to receive the training that they needed if they were Black; experienced financial difficulty; or cared for a Black, female, or Medicaid-enrolled older adult. Meaning The findings suggest concerning disparities in caregivers’ receipt of needed training when managing posthospitalization care transitions for older adults. Author affiliations and article information are listed at the end of this article. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2021;4(3):e211806. doi:10.1001/jamanetworkopen.2021.1806 (Reprinted) March 16, 2021 1/13 Downloaded From: https://jamanetwork.com/ by a Non-Human Traffic (NHT) User on 09/26/2021 Abstract (continued)continued) Black, female, or Medicaid-enrolled older adult. These findings suggest that changes to the discharge process, such as using standardized caregiver assessments, may be necessary to ensure equitable support of family caregivers. JAMA Network Open. 2021;4(3):e211806. doi:10.1001/jamanetworkopen.2021.1806


Methods Sample
This cross-sectional study used data from the 2017 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC), 2 linked national surveys that collect comprehensive information from both older adults and their family caregivers. The NHATS is a nationally representative survey of Medicare beneficiaries 65 years or older in which in-person interviews are used to collect measures of health status, function, and reliance on family caregiving. The NSOC is a companion telephone survey of up to 5 family and unpaid caregivers identified by NHATS participants. The NSOC was first fielded in 2011, with additional waves in 2015 and 2017. This study was deemed not human subjects research by the Johns Hopkins Bloomberg School of Public Health institutional review board because all data are deidentified and publicly available. Informed consent was obtained from survey participants during data collection for the NHATS and NSOC; these datagathering activities were wholly separate from analyses for this study. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
To be eligible for the NSOC, a caregiver must have assisted a community-living older adult with mobility, personal care, or household activities for health and function reasons, or assisted an older adult who lived in a residential care facility. This study focused on caregivers of community-living older adults given that supports available in residential care facilities could substitute for or otherwise affect the need for family caregiving after hospital discharge. Of the 2652 caregivers who completed the 2017 NSOC, the analytic sample for this study included 1905 caregivers who were assisting a community-living older adult at the time of survey. Other caregiver characteristics included sociodemographic data (sex, race/ethnicity, and educational attainment); experiences of financial, emotional, and physical difficulty owing to caregiving; caregiving circumstances (being a sole caregiver, receiving payment for providing care, caregiving for Ն5 years, mean number of hours of care provided per month, and types of assistance provided); and interactions with the health care system (frequency of discussing older adult's care with a clinician in the past year). Race/ethnicity was measured using caregiver self-reports of primary race/ethnicity. Fewer than 10% of respondents identified as Hispanic or another race/ethnicity. Therefore, we created a variable reflecting whether an individual identified as non-Hispanic White, non-Hispanic Black, or other race/ethnicity. Caregiving-related difficulty refers to an affirmative response to the question "Is helping [NHATS participant] [financially/emotionally/physically] difficult for you?" Types of assistance included mobility (ambulation within the home, transferring, and leaving the home), personal care (eating, bathing, toileting, and dressing), health care (managing medications, performing medical tasks, administering shots, and providing wound care), and health care system navigation (making health care appointments and coordinating care).

Measures
We measured older adults' sociodemographic characteristics, including age, sex, race/ethnicity, and Medicaid enrollment, and characteristics associated with the need for caregiver assistance and/or caregiving experiences, including self-reported health status, dementia, and postdischarge destination. 9,35 Race/ethnicity was measured using older adult self-reports of primary race/ethnicity. Because our sample was limited to Medicare beneficiaries 65 years or older, those who were enrolled

Statistical Analysis
Data analysis was performed form June to September 2020. First, we described the characteristics of family caregivers by whether they assisted during a posthospitalization care transition in the year preceding the survey interview. We present unweighted frequencies and weighted percentages as well as the results of weighted Pearson and Wald tests for differences between groups. For all analyses, statistical significance was determined by α < .05 in 2-sided hypothesis tests.
Next, we limited our analyses to caregivers who assisted with posthospitalization transitions and comparatively examined characteristics of caregivers (and their care recipients) by whether the caregiver received adequate transitional care training. We tested for differences between groups using weighted Pearson and Wald tests. We then modeled receipt of adequate transitional care training as a function of individual caregiver characteristics using multivariable, weighted logistic regression. We adjusted for older adult age, sex, self-reported health status, dementia, and postdischarge destination. We excluded older adult race and Medicaid enrollment from these models because these variables were collinear with 2 caregiver characteristics of interest (race/ethnicity and financial difficulty, respectively). All analyses used survey weights and design variables to account for complex, nonprobability sampling and to produce nationally representative estimates. Analyses were conducted using Stata, version 14 (StataCorp LLC).

Results
Of 1905

Limitations
This study has limitations. Information regarding the mode of transitional care training or its effects on caregiver burden or capacity was not available. Similarly, we did not have access to granular information regarding older adults' specific care settings after hospital discharge (eg, skilled nursing, inpatient rehabilitation, or home health care). Given the use of cross-sectional, observational data, causal inferences could not be made. A small number of study participants reported primary race/ethnicities other than White or Black. As a result, we could not evaluate the unique experiences of these caregivers and how they varied; this is a topic that deserves further attention. We did not have access to information regarding the older adults' hospital stays, including diagnoses, duration of the hospital stays, or characteristics of hospitals where care was received. Our estimate of caregiver access to transitional care training is based on data gathered before the COVID-19 pandemic; the current rate of training is likely lower.

Conclusions
In this cross-sectional and nationally representative study of older adults' family caregivers, assisting during a posthospitalization care transition was associated with providing more intensive care and a greater likelihood of caregivers reporting difficulty related to the role. More than half (59.1%) of caregivers who helped an older adult during a posthospitalization care transition in the previous year reported receiving the training that they needed from hospital staff. Caregivers were more likely to report receiving adequate transitional care training if they interacted frequently with the health care system, whereas such training was less likely if caregivers were Black; experienced financial difficulty; or cared for a Black, female, or Medicaid-enrolled older adult. These findings suggest the need for greater support of family caregivers who assist older adults during posthospitalization care transitions and the need for formal, standardized assessment tools to help clinicians identify which caregivers may benefit from transitional care training.