5

Social Services and Other Supports

The fourth session of the workshop focused on the integration of social services and other support environments, which is a critical aspect of multilevel approaches and socio-ecological models to enable dementia care and research. Speakers and workshop participants had been asked to address the following questions: How can local health and social service systems be incorporated into community-level efforts to support people living with dementia, help them to stay in their own homes longer, and minimize adverse consequences? What is the role of physicians and other health care providers to improve quality of life and reduce hospitalization and institutionalization?

EMERGENCY COMMUNITY RESOURCES

Manish Shah (Professor and Chair of the BerbeeWalsh Department of Emergency Medicine, University of Wisconsin–Madison) underscored that people living with dementia have complex, often unpredictable medical and social needs. They often rely on a hospital emergency department (ED) for acute illness care because of limited access to outpatient care, delays in seeking care, and limited availability of rapid outpatient diagnostic testing and therapeutic interventions (Beck et al., 2020; Feng et al., 2014; LaMantia et al., 2016). However, he noted that EDs—with their bright lights, noise, constant interruptions, and overall busy environments—are not an optimal solution to meet the acute care needs of people living with dementia. ED care primarily focuses on identifying and treating life-threatening and time-sensitive conditions, and ED providers have limited health information about people with dementia who visit an ED for an acute issue, creating discontinuity in care (Hwang et al., 2022).

For acute care among people living with dementia who are aging in place with their care partners, Shah proposed two approaches to eliminate or reduce ED visits: (1) identify developing conditions early through assessment and monitoring, educating people living with dementia and their care partners about dementia progression and acute illnesses, and increasing communication channels between a patient and their caregiver dyad and the primary health care team, as well as social services and other community supports; and (2) assess people living with dementia at home and deliver advanced acute illness care in person or via telemedicine, educating and coaching people living with dementia and their care partners about how to handle a particular acute illness and when to seek further care, and collaborating with medical and social services to ensure proper follow-up and support for acute illnesses (Jacobsohn et al., 2019).

Shah then turned to the emergency medical services (EMS) system. Traditionally, it has focused on providing urgent prehospital treatment and stabilization for serious illnesses and injuries, as well as transporting patients to hospitals for care (Shah, 2006). However, the more modern EMS model

embraces a public health role; serves as the community safety net (not just for acute illnesses); leverages its universal presence to help anyone, anywhere; and responds rapidly. For example, the “community paramedic,” a new type of EMS provider, functions outside of the usual emergency response and transport role to reduce ED and hospital use and to support the community’s health. A community paramedic performs public health and prevention activities such as vaccination and screening, educates and coaches patients and care partners, assesses and monitors patients, delivers advanced care to patients without transporting them to the hospital, and collaborates with community-wide resources to support patients. Shah highlighted the strengths and limitations of this approach. On the positive side, a community paramedic is universally present, is highly respected, is knowledgeable about acute illnesses, and has advanced diagnostic and therapeutic capabilities. However, community paramedics have limited disease-specific knowledge, limited mobile diagnostic technologies, and limited ability to access information from and collaborate across systems of care. Furthermore, the scope of practice and licensing are currently unclear, and no dedicated funding is available for the community paramedicine approach.

Shah noted that despite these challenges, emerging evidence suggests that community paramedics could be a valuable resource to help people with dementia to age in place. In terms of efforts to prevent ED visits, he remarked that his team has been adapting the Resources Enhancing Alzheimer’s Caregiver Health (REACH) model¹ to the emergency care setting. The REACH model has been employed by community paramedics in collaboration with primary care clinics to support a pilot effort, funded by the National Institute on Aging (NIA), among people who live in a rural community. This pilot addressed communication and electronic health record challenges and barriers; demonstrated good engagement and participation by community paramedics, people living with dementia, caregivers, and community clinics; and resulted in promising qualitative evidence.

Shah described another effort to prevent ED visits by improving care transitions. He noted that after discharge from an ED, people living with dementia have extremely high rates of return visits to the ED within 30 days. He and his team adapted the care transitions intervention² to create the community paramedic transitions intervention, which is delivered to older patients being discharged from the ED to their homes. He indicated that ED patients with cognitive impairment who received the intervention had significantly reduced odds of a return visit to the ED within 30 days (Shah et al., 2022).

In terms of efforts to substitute for ED visits, Shah described a recent study that tested a high-intensity telemedicine program. It provided home--

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¹ https://www.icpsr.umich.edu/web/ICPSR/studies/03678

² https://caretransitions.health

based acute illness care for older adults living both independently and in assisted living, delivered by technicians with telemedicine and laboratory testing capabilities. The technicians went to the person’s residence, facilitated the telemedicine visit, obtained laboratory specimens, and took the person to the hospital for further testing if needed. He said that for a subgroup of participants with dementia, the intervention decreased ED use by 24% (Gillespie et al., 2019).

Turning to a discussion of methodological considerations for these approaches, Shah indicated that these studies require evaluation for diverse groups of people living with dementia and their care partners (e.g., those with limited English proficiency, those living in rural or low-resource communities), implementation science approaches for translation to practice that involve community members and community organizations, and randomized and pragmatic clinical trials that include diverse populations to evaluate the effectiveness of interventions and inform necessary modifications. Furthermore, he said, infrastructure research and development for community paramedics is needed to support the needs and care of both people with dementia and their care partners.

Developing and testing necessary communication linkages and efficiencies is particularly critical—for example, the interoperability of medical and social service providers, accessibility of integrated medical and social service records, parsing of records for use, and applicability of artificial intelligence. Another opportunity is to develop and test devices to monitor and diagnose acutely ill people with dementia who live at home (e.g., telemonitoring and telehealth technologies, as well as viral and bacterial panels). He noted that artificial intelligence could also be used in collaboration with some of these technologies to reduce the oversight time of providers. Programmatic research and development is also essential, he continued. For instance, to prevent ED visits, he suggested developing and testing a community paramedic–led approach to address the educational and social support needs of people living with dementia and their care partners during acute illness and as the dementia evolves, and to develop and test community paramedic–led programs to enhance transitions between any sites. To substitute for ED visits, he advocated for developing and testing community paramedic–led approaches to deliver acute illness care to people living with dementia without transporting them to the hospital. Although initial research is promising, he stressed that much work remains to improve care options for people aging in place with dementia.

PAID CARE AND FAMILY CAREGIVERS

Chanee Fabius (Assistant Professor in the Department of Health Policy and Management, Bloomberg School of Public Health, John Hopkins University) provided an overview of paid care, which provides assistance with

routine daily activities (e.g., bathing, dressing, preparing meals, administering medication) for people with disabilities. Paid care is found in both traditional home- and community-based settings and in residential care settings, such as assisted living. The goal of delivering paid care typically is to delay or replace the need for nursing home services. Paid care is supported by waivers through Medicaid’s home- and community-based services (HCBS) and administered by states, private pay, or Medicare Home Health. As a result of Medicaid HCBS rebalancing efforts over the past several decades, she explained, many state priorities for financing have shifted from institutional care to HCBS; this creates significant variability in how people access services and what services they can receive, which makes it difficult to assess care quality.

Fabius indicated that paid care is delivered in the United States by the direct care workforce, which is comprised of home care workers (approximately 2.6 million personal care aides, home health aides, and nursing assistants who support individuals in private homes), residential care aides (647,500 personal care aides, home health aides, and nursing assistants who assist individuals in group homes, assisted living communities, and other residential care settings), and nursing assistants (471,000 workers who provide services to individuals living in skilled nursing homes). Home care workers are primarily female immigrants of racial and ethnic minority groups. The national median hourly wage for home care workers was $12.98/hour in 2020 (PHI, 2022).

Presenting an overview of data from the 2011 National Health and Aging Trends Study on the percentage of older adults receiving paid and unpaid care, Fabius noted that 50% of people with three or more self-care or mobility needs receive paid assistance. More than 44% of people in the same category receive both paid and unpaid care (i.e., from family or other caregivers) to address their needs (Freedman & Spillman, 2014). She added that paid and unpaid caregivers often collaborate to provide care to older adults with disabilities who live in their communities.

Fabius turned to a discussion of the racial and ethnic disparities in paid care, for which research on access and experiences is limited and mixed. Some evidence reveals disparities in outcomes such as hospitalizations: For example, among HCBS participants, Black older adults with dementia are more likely to experience hospitalization. However, observed differences in access may be the result of several factors, such as service availability in a particular area or a lack of culturally tailored services (e.g., lack of non-English-speaking agency staff). In Medicare Home Health in particular, racial and ethnic disparities have been observed in the initiation, provision, and quality of services (see Fashaw-Walters et al., 2022; Gorges et al., 2019; Joynt Maddox et al., 2018; Shippee et al., 2022; Yeboah-Korang et al., 2011).

Fabius indicated that older adults living with dementia are more likely to use paid care than those without dementia. Dementia-specific targeted supports are available in some states (e.g., through Medicaid HCBS and assisted living), and limited dementia-specific training is available for direct care workers. However, as a result of disparities in dementia prevalence and level of disability, people who are racial and ethnic minorities that receive paid care may have different service needs than their White counterparts (see Cornell et al., 2020; Fabius et al., 2020, 2022; Garfield et al., 2015; Kasper et al., 2015).

Fabius noted that the use of paid care also varies by stage of dementia. Reckrey et al. (2020) used the 2015 National Health and Aging Trends Study to characterize paid caregiving frequency among community-dwelling older adults with dementia and to identify factors associated with receiving paid care. They found that weekly paid caregiving hours for those with advanced dementia replaced some of the unpaid care previously provided by family caregivers during an earlier stage of dementia. However, even when receiving paid care, these older adults with dementia were more likely than those without dementia to experience adverse consequences from unmet needs (Fabius et al., 2022). In another study that leveraged Maryland Medicaid HCBS data for a sample of older adults, significant differences in low social engagement, hospitalizations, and emergency room use were not observed between those with dementia and those without dementia over a 90-day period; however, a significant number of participants reported not participating in activities they enjoyed. Fabius said that these data suggest that social engagement is a key component of quality of life that should be examined further (Fabius, Millar, et al., 2023).

Fabius also discussed the relationship between family caregivers and paid care. Family caregivers of older adults who receive paid care often report spending time managing paid caregivers in the home, including monitoring and training the caregivers and coordinating care (Reckrey et al., 2022). Family caregivers of people with dementia are typically more involved in service coordination than those of people without dementia. Fabius indicated that among family caregivers, racial differences exist for caregiving intensity, level of disability of the care recipient, available financial resources, and caregiving experiences. She remarked that people from racial and ethnic minorities are more often caring for older adults with dementia with a greater level of disability and with fewer financial resources than nonminorities; however, these caregivers less often report emotional strain or burden related to caregiving (see Fabius et al., 2020; Parker & Fabius, 2022; Reckrey et al., 2022; Travers et al., 2023).

Fabius indicated that family caregivers of older participants in Maryland Medicaid HCBS experienced less burden than the general caregiving population (Fabius, Millar, et al., 2023), but family caregivers of older

adults with dementia were more likely to feel overwhelmed, distressed, angry, depressed, or unable to continue caregiving than those caring for older adults without dementia (Fabius, Millar, et al., 2023). Among caregivers of people with dementia, experiences varied when paid care was used. Those receiving full-time paid care reported the most significant benefit (e.g., less exhaustion; Reckrey et al., 2021): Fabius noted, however, that full-time paid care is out of reach financially for many people.

Given this evidence about existing racial and ethnic disparities in paid care use and experiences and the need to improve paid care for older adults with dementia and their caregivers (with consideration for their cultural experiences and for the roles of and implications for the direct care workforce), Fabius stressed that innovative approaches are needed. She shared the following strategies related to paid care that have been implemented or could be implemented in the future to support all older adults with dementia as well as their family caregivers. First, after conducting qualitative interviews in Maryland, Fabius, Wec et al. (2023) found that communication and collaboration about aspects of care between family caregivers and clinical care teams is critically important for people living with dementia.

Second, Fabius and her team developed a long-term services and support environment framework to help researchers and policymakers better understand state and local place-based characteristics associated with care quality and access experiences of older adults across three domains—social and economic, health care and social services delivery, and built and natural physical environment—and three levels—societal, community, and household (Fabius, Okoye, et al., 2023): see Table 5-1.

Fabius commented that efforts to better support older adults with dementia and their caregivers are also under way at the national level. The 2023 National Research Summit on Care, Services, and Supports for Persons Living with Dementia and Their Care Partners/Caregivers had three recommendations:³

1. Examine how health care policies and payment models differentially affect access and quality of care received by people living with dementia in community settings to guide interventions;
2. Conduct culturally informed research on caregivers’ well-being and the provision of caregiving supports and services; and
3. Conduct research to strengthen the direct care workforce, including increasing available data, understanding the interactions within caregiving teams, and developing equitable interventions.

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³ https://www.nia.nih.gov/2023-dementia-care-summit

TABLE 5-1 A Long-Term Services and Support Environment Framework

NOTES: HCBS, home- and community-based services; LTSS, long-term services and supports; MLTSS, managed long-term services and supports; OAA, Older Americans Act; SDI, Social Deprivation Index; SNAP, Supplemental Nutrition Assistance Program.
SOURCE: Fabius, Okoye, et al. (2023).

The 2022 National Strategy to Support Family Caregivers offered five goals:⁴

1. Increase awareness of and outreach to family caregivers;
2. Advance partnerships and engagement with family caregivers;
3. Strengthen services and supports for family caregivers;
4. Ensure financial and workplace security for family caregivers; and
5. Expand data, research, and evidence-based practices to support family caregivers.

In addition, Fabius reported, the 2023 White House Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers⁵ serves to improve the affordability of long-term services and support, improve access to home-based care for veterans, enhance job quality and compensation for the direct care workforce, and support family caregivers. In closing, Fabius underscored that policy, research, and practice all play a key role in increasing knowledge and addressing issues related to paid care delivery disparities and family caregivers.

LOS ANGELES COUNTY AGING AND DISABILITIES DEPARTMENT

Laura Trejo (Director, Los Angeles County Aging and Disabilities Department) described her work to change policy at the macro and micro levels to ensure that the needs of Los Angeles County’s aging population and people with disabilities are met, as well as to demonstrate the impact of those efforts. A 4,000-square-mile region incorporating 88 cities, Los Angeles County is a challenging environment in which to provide services for older people.

Trejo explained that as the third leading cause of death in Los Angeles County, Alzheimer’s disease is now influencing policy, systems, and service delivery. She first highlighted an age-friendly initiative launched in 2016 that engaged more than 22 elected officials in the region and prioritized not only age-appropriateness, accessibility, and inclusiveness but also dementia-friendly components.⁶

Trejo noted that her team works continuously to help the Los Angeles County community understand how to respond to the changing needs of its residents. For example, an effort that began at the regional level 3 years

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⁴ https://acl.gov/CaregiverStrategy

⁵ https://www.whitehouse.gov/briefing-room/presidential-actions/2023/04/18/executive-order-on-increasing-access-to-high-quality-care-and-supporting-caregivers

⁶ https://purposefulagingla.com/index.html

ago to develop a strategic plan for brain health⁷ incorporates several dimensions. Given the diversity of the community, one of these dimensions is evaluating implications of health disparities among people with dementia, with particular attention to linguistic and cultural issues in service delivery, assessment, and intervention (see, e.g., previous work from Aranda et al., 2003). She indicated that Los Angeles County is also considering implementing a framework with a lifespan approach to evaluate how the county is investing its resources to improve the quality of life for its residents.

Trejo pointed out that because several different systems play a role in delivering care to people with dementia and providing support to their families, the county is increasing its cross-sector collaborations. For instance, her office collaborated with the county’s public health director to begin strategic brain health planning for its aging population. As another example of effective cross-sector collaboration, she explained that her team worked with local law enforcement to launch L.A. Found,⁸ an intervention that provides global positioning system tracking devices to family members to help locate people with dementia who have wandered from their homes.

Trejo and her team are also considering workforce opportunities in the county that could be leveraged to improve the early identification of people’s medical conditions and needs (especially among minority populations) and the needs of their caregivers and thus improve the provision of care. To provide better support, especially for family caregivers, she and her team are reviewing records of who visits the emergency room and what care they receive. The goal of this effort is to improve continuity of care with better follow-up communication. For example, an emergency alert response system intervention allows families to call 911 and participate in a screening process to determine whether an emergency room visit is warranted for their loved one, and this screening call is followed up with social services and supports. She indicated that this intervention has demonstrated a decrease in the high utilization of expensive, unnecessary emergency care.

Trejo noted that community-wide education is another important goal in the county. For example, Dementia Friends LA⁹ was launched by first engaging elected officials and then by creating an ambassador program throughout the community. She expressed her hope that such strategic initiatives will begin to change the way community members respond to people experiencing dementia.

Trejo underscored that implementing and measuring the effectiveness of such strategic initiatives at the local level requires support and funding from policymakers (see, e.g., Aranda et al., 2021). She urged vigilance at both the policy and program levels as the field of dementia care continues to evolve;

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⁷ http://publichealth.lacounty.gov/seniorhealth/abouthbla

⁸ https://lafound.lacounty.gov

⁹ https://www.alzheimersla.org/for-communities/dementia-friends

including people with dementia and their caregivers in this important work remains critical. Exciting work is ongoing at the community level, she continued, including collaborations with universities and other research partners, to document this work and expand the field. She stressed that these partnerships create a key opportunity for underserved populations to be included in research.

DISCUSSION

Sharing questions from workshop participants, Amy Kind (Associate Dean for Social Health Sciences and Programs at the University of Wisconsin–Madison; planning committee member), moderated a discussion among the session’s three speakers. She invited each to discuss an important research opportunity to improve social services, connectivity, and support networks for people with dementia and their families.

Trejo urged NIA to examine how Alzheimer’s Demonstration Grants have affected systems of care in the communities that received them. Fabius highlighted the lack of data available on the direct care workforce, especially on a statewide or national scale, which makes formulating key research questions and providing meaningful recommendations for family caregivers very difficult. Shah noted that more research is needed to develop strategies to support older people living with dementia and their care partners as acute illness develops and dementia evolves—without going to EDs.

Kind asked Shah to describe the responsibilities of community paramedics, especially when they encounter people with dementia who live alone. Shah reiterated that a community paramedic’s primary goal is to avoid transporting the person to the hospital—for example, by repairing a person’s laceration in the home. He advocated for the development of a support structure specifically for people who live alone to ensure that they are not putting themselves at increased risk.

In response to Kind’s observation that social isolation is a crosscutting theme of the workshop, Fabius explained that she found low levels of social engagement for older people in general in her research and noted that social engagement and social isolation are important measures of quality of care. She stressed that having a person in one’s house does not guarantee meaningful engagement; further research could help determine how HCBS could best address such social engagement issues. Trejo described a policy position adopted by the Board of Supervisors in Los Angeles County that focuses on the importance of social connectedness. Approximately 30 county departments are working together to determine what each can do to improve the “social fabric” of the community—for example, by embracing the role of culture in improving health access and wellness among older adults.

Emily Agree (Research Professor and Associate Director, Hopkins Population Center, Johns Hopkins University; planning committee chair)

asked about the role of language in service delivery to communities. Trejo responded that appropriate language skills are incredibly important to providing quality care; when people are in distress, they often communicate in their native language. To provide the best care, she championed the use of peer-support strategies as a way to educate and empower both communities and older adults, and she suggested adding professionals with language skills to a community’s support networks instead of asking families to have their own interpreters. She added that professionals who speak another language need to be recognized and rewarded for the value they provide to their communities.

Fabius agreed that language skills are highly valuable. For example, she said, people should not have to travel exceptionally long distances just to find an adult day center with staff who speak their language. Similarly frustrating situations arise in nursing home settings when only one staff person speaks the native language of a resident, causing the resident to feel isolated. Fabius emphasized that if agencies began to compensate staff appropriately for critical language and communication skills, language barriers could be addressed and high turnover rates of paid care positions could be decreased. Shah remarked that language barriers are also a significant challenge in emergency medicine, especially given the limited diversity among clinicians and paramedics. He underscored that in addition to speaking the language, being part of the community and the culture is essential; for example, when people from rural areas serve as paramedics in their communities, this builds trust and capacity and improves job fulfillment.

Wendy Rogers (Khan Professor of Applied Health Sciences, University of Illinois Urbana-Champaign; planning committee member) inquired about the best strategies for providing dementia training to paid caregivers, paramedics, and other support workers. Fabius noted that only 14% of home care agencies surveyed in Maryland require dementia-specific training, even though most of their clients have dementia. She said that additional evidence needs to be developed and then communicated to demonstrate how increased dementia training, tailored to the unique settings of assisted living and personal residences, improves both care delivery and caregiver knowledge. She highlighted another challenge in that without any national requirements for training, training is at the state’s or specific agency’s discretion, and decisions are affected by cost and staff availability.

Shah noted that because paramedics and ED staff already have so much training to complete, adding dementia-specific training is a challenge. However, building a community paramedic program focused specifically on people with dementia would reduce the number of people who need this training. He stressed that further research is needed to determine key competencies and milestones as well as evaluation measures for such training.

Trejo suggested first identifying the workforce that needs to be trained and then determining the minimum amount of training needed for that

workforce to perform appropriately. When the training is focused properly, she continued, the workforce is more likely to complete it. For example, in her role to develop protocols for frontline clinical staff who need to acquire a new skill, she reviews validated standard instruments and adapts them as appropriate for the applied setting to train the workforce.¹⁰

Reflecting on another crosscutting theme of the workshop, the importance of cross-sector collaboration, Kind asked what critical research and infrastructure investment are needed to improve connectivity across siloed community systems. Trejo observed that no shared definition of terms exists across agencies, which creates stress for families and those trying to create programs for the community. She advocated for developing a standard lexicon at the federal level across systems, which would also improve data alignment. To improve cross-sector collaboration further, she said, dedicated leadership for improving care of people aging with dementia is needed at the community level.

Fabius discussed the role of embedded pragmatic clinical trials in facilitating collaborative efforts; these efforts could help overcome the issues that arise when people work in silos and neither the data nor the people talk to one another, resulting in the same findings. Shah added that the EMS system has always operated within a silo: it has a massive amount of information but no way to communicate it with other service agencies or health systems. Without this capability, he continued, providing the holistic and comprehensive support that people, especially older people with dementia, need is not possible.

Kind posed a question about how to support this research and practice on a fiscal level. Trejo advocated for increased partnership between those in applied settings and those in academia. She encouraged community leaders to “shop their questions around” the research community, find someone who can help answer them, and then provide justification to a policymaker for financing. Because making such connections is sometimes difficult, she suggested that the research community initiate partnerships as well. Shah urged researchers to think more broadly about important outcome measures for community programs and identified the challenge of crossing social and medical service domains, which have unique complexities in measuring cost and best supporting activities. He also championed increased partnerships, noting that academic institutions welcome and often seek out collaborative opportunities with community groups. Fabius agreed that partnership is key to moving the field forward, and she “keeps her ear to the street” to understand what critical questions need to be answered for the community. She also indicated that Medicaid HCBS could learn lessons from how states used American Rescue Plan Act funds (e.g., expanding services, reducing waiting lists) and which strategies worked best.

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¹⁰ https://file.lacounty.gov/SDSInter/dmh/159942_the_oa_geriatric_field_screening_protocol.pdf

SUMMARY OF WORKSHOP DAY 2

In closing the discussion, Elena Fazio (Director of the Office of Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias Strategic Coordination in the Division of Behavioral and Social Research, NIA) identified themes that emerged during the second day of the workshop: (a) the importance of focusing more specifically on people with dementia aging in place or in the community; (b) the need to focus on workforce training and availability; (c) the value of both collective and individual services for people with dementia aging in place; (d) the exploration of what it means to live where you want to live, with consideration of how that choice is made and who can make it; (e) recognition of the disparities in health care access; and (f) an understanding of how housing interacts with aging in place and beyond. Fazio also mentioned a new NIA funding opportunity for a state dementia care research center that will focus on dementia care practices, policies, and programs that are working at the state and substate levels.

Agree followed with a summary of her key takeaways from the third and fourth sessions of the workshop. She noted that several speakers discussed strategies to evaluate successful programs for aging in place for people with dementia, building on previous workshop conversations about the ambiguous concept of place and the fact that some people want to stay in the homes in which they have always lived while others are “trapped” in unmanageable environments. Thus, some speakers highlighted the concept of “aging in the right place,” a perspective that may change as dementia progresses and as family resources and needs evolve. She noted that speakers explained that understanding the triggers that indicate that people with dementia and their families need more assistance is a key component to adapting environments to people.

Agree mentioned that one speaker described the critical role of paid care workers and how much they improve the experiences for unpaid family members providing and managing care; however, too little is known about the direct workforce and its challenges. Innovative strategies could improve information exchange between workers, families, and systems, as well as coordination of care.

Agree also observed that several speakers commented on how unaffordable housing affects one’s ability to pay for necessities (e.g., care, medicine, food), and a home’s inaccessibility limits social engagement. In light of these concerns, many speakers noted that policies need to be examined more closely, as housing and health policies are rarely coordinated.

Agree noted that a few speakers emphasized that research on dementia-friendly community initiatives should build capacity for evaluation into the intervention design. Furthermore, to be sustainable, they suggested that programs not begin without assessing the resources in a community, as well as the benefits of investing in those communities.

Lastly, Agree reported that speakers also discussed social and other supportive service environments, highlighting opportunities for coordination and identifying unique resources in communities that can help facilitate aging in place with dementia. For example, an opportunity exists to better leverage paramedics to improve transitions between settings and to avoid transporting people to emergency rooms through education and delivery of acute care services. Other opportunities include the potential to set up 911 screening to notify social services of an emergency room visit. A few speakers discussed the importance of cross-sector collaborations and the potential benefits of involving other community systems in working with social service and supportive programs.

REFERENCES