The nation’s acute shortage of home health aides is jeopardizing care for vulnerable older adults

By  JUDITH GRAHAM, KAISER HEALTH NEWS

Acute shortages of home health aides and nursing assistants are cropping up across the country, threatening care for people with serious disabilities and vulnerable older adults.

In Minnesota and Wisconsin, nursing homes have denied admission to thousands of patients over the past year because they lack essential staff, according to local long-term care associations

In New York, patients living in rural areas have been injured, soiled themselves and gone without meals because paid caregivers aren’t available, according to testimony provided to the state Assembly’s health

In Illinois, the independence of people with severe developmental disabilities is being compromised, as agencies experience staff shortages of up to 30 percent, according to a court monitor overseeing a federal consent decree.

The emerging crisis is driven by low wages — around $10 an hour, mostly funded by state Medicaid programs — and a shrinking pool of workers willing to perform this physically and emotionally demanding work: helping people get in and out of bed, go to the bathroom, shower, eat, participate in activities, and often dealing with challenging behaviors.

It portends even worse difficulties to come, as America’s senior citizen population swells to 88 million people in 2050, up from 48 million currently, and requires more assistance with chronic health conditions and disabilities, experts warn.

“If we don’t turn this around, things are only going to get worse” said Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association, which represents nursing homes across the U.S.

“For me, as a parent, the instability of this system is terrifying,” said Cheryl Dougan of Bethlehem, Pa., whose profoundly disabled son, Renzo, suffered cardiac arrest nearly 19 years ago at age 14 and receives round-the-clock care from paid caregivers.

Rising demand, stagnant wages

For years, experts have predicted that demand for services from a rapidly aging population would outstrip the capacity of the “direct care” workforce: personal care aides, home health aides and nursing assistants.

The U.S. Bureau of Labor Statistics estimates an additional 1.1 million workers of this kind will be needed by 2024 — a 26 percent increase over 2014. Yet, the population of potential workers who tend to fill these jobs, overwhelmingly women ages 25 to 64, will increase at a much slower rate.

After the recession of 2008-09, positions in Medicaid-funded home health agencies, nursing homes and community service agencies were relatively easy to fill for several years. But the improving economy has led workers to pursue other higher-paying alternatives, in retail services for example, and turnover rates have soared.

At the same time, wages for nursing assistants, home health aides and personal care aides have stagnated, making recruitment difficult. The average hourly rate nationally is $10.11 — a few cents lower than a decade ago, according to PHI, an organization that studies the direct-care workforce. There is a push on now in a handful of states to raise the minimum to $15 an hour.

Even for-profit franchises that offer services such as light housekeeping and companionship to seniors who pay out-of-pocket are having problems with staffing.

“All the experienced workers are already placed with families. They’re off the market,” said Carrie Bianco, owner of Always Best Care Senior Services, which is based in Torrance, Calif., with franchises in 30 states.

Finding new employees was so difficult that Bianco started her own 14-week training program for caregivers nine months ago. To attract recruits, she ran ads targeting women who had left the workforce or been close to their grandparents. In exchange for free tuition, graduates must agree to start working for her agency.

“There’s much more competition now — a lot of franchises have opened and people will approach our workers outside our building or in the lobby and ask if they want to come work for them,” said Karen Kulp, president of Home Care Associates of Philadelphia.

Hardest to cover in Kulp’s area are people with disabilities or older adults who live at some distance from the city center and need only one to two hours of help a day.  Workers prefer longer shifts and less time traveling between clients, so they gravitate to other opportunities and “these people are not necessarily getting service,” she said.

It isn’t possible to document exactly how common these problems are nationally. Neither states nor the federal government routinely collect information about staff vacancy rates in home care agencies or nursing homes, turnover rates or people going without services.

“If we really want to understand what’s needed to address workforce shortages, we need better data,” said Robert Espinoza, vice president of policy at PHI.

Hard times in Wisconsin

Some of the best data available come from Wisconsin, where long-term care facilities and agencies serving seniors and people with disabilities have surveyed their members over the past year.

The findings are startling. One of seven caregiving positions in Wisconsin nursing homes and group homes remained unfilled, one survey discovered; 70 percent of administrators reported a lack of qualified job applicants. As a result, 18 percent of long-term facilities in Wisconsin have had to limit resident admissions, declining care for more than 5,300 vulnerable residents.

“The words ‘unprecedented’ and ‘desperate’ come to mind,” said John Sauer, president and chief executive of LeadingAge Wisconsin, which represents not-for-profit long-term care institutions. “In my 28 years in the business, this is the most challenging workforce situation I’ve seen.”

Sauer and others blame inadequate payments from Medicaid — which funds about two-thirds of nursing homes’ business — for the bind. In rural areas, especially, operators are at the breaking point.

“We are very seriously considering closing our nursing facility so it doesn’t drive the whole corporation out of business,” said Greg Loeser, chief executive of Iola Living Assistance, which offers skilled nursing, assisted living and independent living services in a rural area about 70 miles west of Green Bay.

Like other short-staffed operators, he’s had to ask employees to work overtime and use agency staff, increasing labor costs substantially. A nearby state veterans home, the largest in Wisconsin, pays higher wages, making it hard for him to find employees. Last year, Iola’s losses on Medicaid-funded residents skyrocketed to $631,000 — an “unsustainable amount,” Loeser said.

Wisconsin Gov. Scott Walker has proposed a 2 percent Medicaid increase for long-term care facilities and personal care agencies for each of the next two years, but that won’t be enough to make a substantial difference, Loeser and other experts say.

The situation is equally grim for Wisconsin agencies that send personal care workers into people’s homes. According to a separate survey in 2016, 85 percent of agencies said they didn’t have enough staff to cover all shifts, and 43 percent reported not filling shifts at least seven times a month.

Barbara Vedder, 67, of Madison, paralyzed from her chest down since a spinal cord injury in 1981, has witnessed the impact firsthand. Currently, she qualifies for 8.75 hours of help a day, while her husband tends to her in the evening.

“It’s getting much, much, much more difficult to find willing, capable people to help me,” she said. “It’s a revolving door: People come for a couple of months, maybe, then they find a better job or they get pregnant or they move out of state. It’s an endless state of not knowing what’s going to happen next — will somebody be around to help me tomorrow? Next month?”

When caregivers don’t show up or shifts are cut back or canceled, “I don’t get proper cleaning around my catheter or in my groin area,” Vedder continued. “I’ll skip a meal or wait later several hours to take a pill. I won’t get my range-of-motion exercises, or my wheelchair cushion might slip out of place and I’ll start getting sore. Basically, I start losing my health.”

Debra Ramacher and her husband have been unable to find paid caregivers since June 2015 for daughter Maya, 20, and son Michael, 19, both of whom have cerebral palsy, epilepsy and other significant disabilities. The family lives in New Richmond in western Wisconsin, about 45 minutes from the Minneapolis-St. Paul metropolitan area.

“At least three agencies told me they’ve stopped trying to hire personal care aides. They can’t find anybody and it costs them money to advertise,” said Ramacher, executive director of Wisconsin Family Ties, an organization for families with children with emotional, behavioral and mental disorders.

“It’s incredibly stressful on all of us, living with this kind of uncertainty,” she said.

Every few months, Ramacher tries to find caregivers on her own by putting ads up on Craigslist, in local newspapers and on job boards.

“We get a few bites,” she said. “Most recently, two people came and interviewed. One never got back to us; the other got a better job that paid more.”

In the meantime, she and her husband are being paid by Medicaid to look after Maya and Michael.

“We don’t want to be the caregivers; we want to have our own life,” Ramacher said. “But we don’t have any option.”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Are We More Risk Averse as We Get Older? It’s a Gray (Matter )

Newswise, December 26, 2016 — Age itself is not the determining factor in how an individual views or tolerates risk when making decisions; instead, it is the age-related decline in the volume of gray matter in our brains, research by NYU’s Institute for the Interdisciplinary Study of Decision Making shows.

“These results provide a basis for understanding the neural mechanisms involved in risky choices and offer a glimpse into the dynamics that affect decision-making in an aging population,” explains study co-author Paul Glimcher, a professor at NYU’s Center for Neural Science and director of the Interdisciplinary Study of Decision Making (IISDM).

“This research can help us improve how we communicate with the elderly about complex issues that may present risks to them.”

“Older adults need to make many important financial and medical decisions, often under high levels of uncertainty,” adds lead author Ifat Levy, an associate professor of comparative medicine and of neuroscience at Yale University and visiting professor at IISDM.

“We know that decision making changes with age, but we don’t really know what the biological basis of these changes is. In this paper, we make the first step towards answering this question, by showing that the decrease in gray matter volume in a particular part of the brain – posterior parietal cortex – accounts for the increase in risk aversion observed with age."

The study, which appears in the journal Nature Communications, focused on the right posterior parietal cortex (rPPC)—a part of the brain involved in planning movements, spatial reasoning, and attention.

For the study, the research team presented a series of choices to 52 study participants, aged 18 to 88 years. Participants could either receive $5 or take their chances with a lottery of varying amounts and probabilities.

For example, a participant could choose the certain gain of $5 or opt for a 25 percent chance of getting $20. The researchers also measured the gray matter volume in the posterior parietal cortex of each subject, drawn from MRI scans.

After analyzing the risk choices and MRI measurements, the researchers confirmed that age-related decline in risk tolerance correlates more with changes in brain anatomy than with age.

The study’s other authors were: Michael Grubb, an NYU postdoctoral fellow at the time of the study and now an assistant professor at Trinity College in Connecticut; Agnieszka Tymula, a senior lecturer at the University of Sydney; and Sharon Gilaie-Dotan, a postdoctoral fellow at University College London.

The research was supported by grants from the National Institutes of Health (R01 5R01AG033406, R21AG049293); the DOI for this paper will be 10.1038/NCOMMS13822.

SURVEY: MOST OF US WANT MORE REST AND WELL-BEING

Newswise, October 3, 2016 — Over two thirds (68 per cent) of the public would like more rest, according to the world’s largest ever survey on the topic.

The results of the survey, led by Durham University researchers, also revealed that nearly a third (32 per cent) of respondents said they need more rest than the average person, while 10 per cent think they need less.

Rest and well-being

More than 18,000 people from 134 different countries took part in the Rest Test, an online survey to investigate the public’s resting habits and their attitudes towards relaxation and busyness, and the results were unveiled during BBC Radio 4’s programme The Anatomy of Rest.

The survey found that those who felt they needed more rest scored lower in terms of well-being.

Similarly, those who responded saying they think they get more rest than average or don’t feel in need of more rest, had well-being scores twice as high as those who wanted more rest. This suggests that the perception of rest matters, as well as the reality.

Dr Felicity Callard, principal investigator on the project and social scientist in the Department of Geography,said: “The survey shows that people’s ability to take rest, and their levels of well-being, are related. We’re delighted that these findings combat a common, moralizing connection between rest and laziness.”

Five most restful activities

The survey asked people to choose the activities that they find the most restful. The results show that the top five most restful activities are those often done alone:

Reading (58 per cent)
Being in the natural environment (53.1 per cent)
Being on their own (52.1 per cent)
Listening to music (40.6 per cent)
Doing nothing in particular (40 per cent)

Dr Felicity Callard continued: “It’s intriguing that the top activities considered restful are frequently done on one’s own. Perhaps it’s not only the total hours resting or working that we need to consider, but the rhythms of our work, rest and time with and without others.”

Modern life

The results of the survey come at a time when the urge to be busy defines modern life and the topic of rest is at the forefront of many people’s minds. Rest can seem hard to find, whether in relation to an exhausted body, a racing mind or a hectic city.

Rest is a much broader category than sleep, and has physical, mental and spiritual components. But much less is known about the potentially restorative benefits of rest – in part because it means different things to different people.

The survey asked respondents to state how many hours rest they had within the last 24 hours.

The results showed that, on average, being younger and having a higher household income was associated with having fewer hours of rest. Those with caring responsibilities or in shift work which included nights also reported fewer hours of rest. The average time spent resting by UK respondents the previous day was 3 hours and 8 minutes.

Pressing issue

Claudia Hammond, presenter of Radio 4’s All in the Mind and associate director of Hubbub, said:

“We had no idea how many people would choose to complete the Rest Test. More than 18,000 gave up their precious sparetime to tell us what they thought about rest which shows us what a pressing issue it is. These results show just how crucial it is to our well-being to ensure people do have time to rest. We can begin to try to work out what the optimum amount of rest might be and how we should go about resting.”

The Rest Test has been designed by Hubbub, an international collective of social scientists, artists, humanities researchers, scientists, broadcasters, public engagement professionals and mental health experts, in residence at the Hub at Wellcome Collection in London, led by Durham University.

A full analysis of the data will be published in the next year. Hubbub hope the results will increase understanding of people’s perceptions of rest and the way these relate to an individual’s work or daily habits, as well as their experiences of health, illness, disability, satisfaction with life and the tendency to mind wander.

The results coincide with a new exhibition Rest & its discontents open at Mile End Art Pavilion from 30 September-30 October and a new Hubbub publication The Restless Compendium available free to download or to buy as a hard copy from 27 Septemberwww.hubbubresearch.org/publications.

Physical Declines Begin Earlier Than Expected Among U.S. Adults

Newswise, August 10, 2016– Physical declines begin sooner in life than typically detected, often when people are still in their 50s, according to a Duke Health study that focused on a large group of U.S. adults across a variety of age groups.

The finding suggests that efforts to maintain basic strength and endurance should begin before age 50, when it’s still possible to preserve the skills that keep people mobile and independent later in life.

“Typically, functional tests are conducted on people in their 70s and 80s, and by then you’ve missed 40 years of opportunities to remedy problems,” said Miriam C. Morey, Ph.D., senior fellow in the Center for the Study of Aging and Human Development at Duke University School of Medicine. Morey is senior author of research published in the Journals of Gerontology: Medical Sciences.

Morey and colleagues studied a group of 775 participants enrolled in the Measurement to Understand the Reclassification of Disease Of Cabarrus/Kannapolis (MURDOCK) Study.

The MURDOCK Study is Duke Health’s longitudinal clinical research study based at the North Carolina Research Campus in Kannapolis, N.C. The MURDOCK community registry and bio-repository includes more than 12,000 participants and nearly 460,000 biological specimens.

For the MURDOCK Physical Performance Lifespan Study, the Duke-led team enrolled participants ranging in age from their 30s through their 100s, with broad representation across sexes and races.

All participants performed the same simple tasks to demonstrate strength, endurance or balance: rising from a chair repeatedly for 30 seconds; standing on one leg for a minute; and walking for six minutes. Additionally, their walking speed was measured over a distance of about 10 yards.

Men generally performed better than women on the tasks, and younger people outperformed older participants.

But the age at which declines in physical ability began to appear – in the decade of the 50s – were consistent regardless of gender or other demographic features.

Specifically, both men and women in that mid-life decade began to slip in their ability to stand on one leg and rise from a chair. The decline continued through the next decades. Further differences in aerobic endurance and gait speed were observed beginning with participants in their 60s and 70s.

The study provides physical ability benchmarks that could be easily performed and measured in clinical exams, providing a way to detect problems earlier.

“Our research reinforces a life-span approach to maintaining physical ability – don’t wait until you are 80 years old and cannot get out of a chair,” said lead author Katherine S. Hall, Ph.D., assistant professor of medicine at Duke.

“People often misinterpret ‘aging’ to mean ‘aged’, and that issues of functional independence aren’t important until later in life. This bias can exist among researchers and healthcare providers, too. The good news is, with proper attention and effort, the ability to function independently can often be preserved with regular exercise.”

Hall and Morey said the next phase of research will be to study blood samples of the participants to determine whether there are biological markers that correlate with declines in physical ability. They are also revisiting the study participants for two-year checkups.

In addition to Hall and Morey, study authors include Harvey J. Cohen, Carl F. Pieper, Gerda G. Fillenbaum, William E. Kraus, Kim M. Huffman, Melissa A. Cornish,Andrew Shiloh,Christy Flynn, Richard Sloane, and L. Kristin Newby.

The study received funding from a philanthropic gift to Duke University from the David H. Murdock Institute for Business and Culture. Additional funding was provided in part  by the Claude D. Pepper Older Americans Independence Center program of the National Institute on Aging (P30AG028716) and the National Center for Research Resources, a component of the NIH (UL1TR001117).

The authors reported no conflicts of interest associated with this research.

CalPACE Supports Budget Measures to Boost Care Program for Frail Elderly

June 15, 2016 /PRNewswire/ -- Among various health care spending priorities and policy changes, the budget the Legislature sends to Governor Brown this week contains measures designed to expand the Program of all-Inclusive Care for the Elderly (PACE), an important care program for low-income frail seniors.

"We appreciate the administration's willingness to modernize PACE, particularly the payment and regulatory aspects," said California PACE Association (CalPACE) Board Chair Linda Trowbridge.

"If structured appropriately, the legislation will allow PACE to expand and serve additional older adults and frail seniors who want to live independently."

Established in the 1970s in San Francisco as a novel way of keeping frail seniors living in the community as long as possible, PACE provides and coordinates an array of medical, social, and long-term care services and supports to help keep frail seniors out of hospitals and nursing facilities. Eleven PACE organizations currently serve nearly 6,000 seniors statewide in 12 counties.

While demand for the program has been growing, outdated payment and regulatory systems have prevented the program from reaching its full potential. 

Payments for PACE providers are tied to costs incurred in the state's fee-for-service Medi-Cal program, which is rapidly shrinking due to the growing use of managed-care plans to deliver services for beneficiaries. Disparities in rates and questions about the adequacy of the rates have plagued the program for years. The program operates under a complicated network of federal and state requirements that necessitate lengthy approval processes for both new and expanded programs.

Recognizing this, the Brown administration introduced legislation as part of its 2016-17 budget proposal in January to revamp the PACE reimbursement structure and create additional regulatory flexibility for the program. 

Under the legislation, payments would be based on the actual costs of serving beneficiaries with a goal of providing more accurate and fair payments and aligning the payment methodology more closely with the methods the state uses to pay managed-care plans. 

The legislation also requires the state to seek greater regulatory flexibility for PACE from the federal Centers for Medicare and Medicaid Services for operational aspects of PACE.

These include the make-up and operation of PACE interdisciplinary care teams, the programs' ability to contract for services with community-based physicians and other senior service providers, and the ability to market PACE services.

Assuming the new rate methodology is approved by the federal government, a current cap on the number of PACE organizations that can operate in the state would be lifted and, for the first time, for-profit organizations would be allowed operate PACE programs, bringing state law into conformity with recent federal regulatory changes.

Both provisions are expected to increase the number of programs as well as the geographic areas served by PACE.

In response to requests from PACE organizations, the final legislation requires the new payment methodology to take into account the unique features of PACE, including its use of dedicated care centers to deliver and coordinate care. 

In addition, the legislation contains provisions to ensure the payment methodology accounts for high-cost conditions, such as Hepatitis C, recognizes the higher costs of start-up programs, and mitigates financial impacts on PACE programs during the transition to the new rate methodology. 

In conjunction with the legislation, the state has committed to further streamlining the application process for new and expanding programs, including the use of a new electronic application process and providing concurrent review of applications by the state and federal governments, which is expected to speed up the review of applications.

"We are grateful the Department of Health Care Services has worked with PACE providers on the issues and concerns we've put forward," noted CalPACE Chief Executive Officer Peter Hansel. "This is a win-win for the state and PACE and, most importantly, for the individuals the programs serve."

CalPACE is dedicated to the expansion of comprehensive healthcare services to seniors with chronic care needs through PACE. Through education and advocacy, CalPACE members strive to support, maintain and safeguard the PACE model and promote high-quality healthcare services to California's seniors.

A New Challenge for Caregivers: The Internet

As people age, how do they manage their online information?

Newswise, June 1, 2016. --- What should caregivers do when their loved one is checking in on social media at the bank, essentially announcing their whereabouts? What if they are posting too often or don’t remember making online purchases?

In the age of online living, caregivers lack support, resources and guidelines to help the vulnerable people who rely on them, according to an initial study, presented at the Association for Computing Machinery Human Computer Interaction (ACM-CHI) conference in San Jose, California.

The study is one of the first to examine the role of caregivers in the online lives of adults with cognitive impairments from Alzheimer’s disease and other conditions.

 In a world where many everyday activities have moved online, caregivers face a new challenge: finding a balance between autonomy and protection of care recipients.

“We want people to stay independent and engaged online, but current online systems make it difficult to help people in a way that empowers them without reducing their access,” said lead researcher Anne Marie Piper, assistant professor in the department of communication studies at Northwestern’s School of Communication.

“E-mail and social media sites aren’t designed to have a caregiver come alongside someone with cognitive impairments and help them stay active online.”

The researchers used focus groups consisting of 20 people informally caring for loved ones with Alzheimer’s, dementia and other brain-related conditions.

They detailed four main ways caregivers currently help people with cognitive impairments use the Internet -- “guiding, stimulating, connecting, and protecting,” with guidelines about how to improve those dynamics.

Caregivers could set up family accounts to support home computer use among family members. They also should learn how to recognize when vulnerability may be transitional, such as a gradual recovery after a stroke or a progression from early to late stage dementia.

Finally, the researchers recommended implementing a system that would allow caregivers to detect risky online situations.

For example, if a password or credit card were disclosed, a transaction would be held for review by the primary caregiver. These ideas, however, raise new ethical questions about who has control over a person’s online life, Piper said.

“Technological caregiving is a new form of work,” Piper said. “We hear about the physical, financial and social stress of caregiving, but no one ever talks about the burden caregivers feel to keep people active online, which we feel is a fundamental part of participating in society.”

According to the study, caregivers support online activity in the following ways:

Guiding: Caregivers may help someone type words into a search engine or operate a mouse. Even previously tech-savvy care recipients may need to re-learn how to use a specific technology.

“What’s challenging is that cognitive impairment is dynamic, and an individual’s needs may shift day-to-day or even moment-to-moment,” Piper said.

Stimulating: Social media can be a form of entertainment or stimulation. Caregivers play “brain games,” read news sites or view online photos of family members. “This interaction can help alleviate some of the burden of caregiving and provide a mutual source of enjoyment,” the researchers found. It also means caregivers have to spend time searching for content, identifying meaningful photos or videos and working it into a conversation.

Connecting: Facebook is a particularly important site for social support, caregivers said. In the study, they mentioned posting weekly updates on Facebook, Instagram, Blogger.com and Caregiver.com.

The ways caregivers post online information “introduces tensions around surrogacy, privacy and information sharing for vulnerable populations,” the researchers wrote.

Protecting: Caregivers use spam filters and set restrictive privacy settings to help avoid phishing and to block harmful websites, friend requests or potentially upsetting information.

They vigilantly watch for online financial threats. “The challenge is deciding when and under what circumstances a care recipient should not have access to credit card information required for online purchases,” the researchers wrote. “Sometimes it’s not until an adverse event like identity theft or overspending that the caregiver realizes they need to protect their care recipient online.”

Link Between Sleep and Social Participation May Be Key to Healthy Aging

Newswise, March 3, 2016 – Sleep may be one of the most important factors for well-being; yet, according to the CDC, one in three adults does not get enough. 

Lack of sleep can lead to potential cognitive declines, chronic diseases and death. Now, research from the University of Missouri finds that older adults who have trouble sleeping, could benefit from participating in social activities, in particular attending religious events. 

“Social connectedness is a key component for health and well-being for older adults,” said Jen-Hao Chen, assistant professor of health sciences at the MU School of Health Professions and the Truman School of Public Affairs. “Close connections to, and participation in, social groups provides a sense of belonging and can be essential for healthy aging.”

Yet despite past attention to the link between social participation and many different health outcomes, little research has been dedicated to linking social participation and another critical health outcome for older adults—sleep.

To study the relationship between sleep and social participation for older adults, Chen analyzed two waves of data collected over a five year period from the National Social Life, Health and Aging Project. 

He looked at three aspects of social participation; volunteering, attending religious services and being part of organized group activities. He then compared the data to sleep outcomes measured by actigraphy—wearable wrist sleep trackers. Results showed that older adults with greater levels of social participation were getting better sleep.

However, Chen says despite the strong associations between social participation and sleep, social participation does not necessarily lead to better sleep. The strong associations he found could also be due to those already sleeping well may feel well enough to be more active socially. His future research on sleep will continue to use innovative sleep measurements to understand the role various social relationships have on sleep behaviors and outcomes.

“When it comes to the discussion of healthy lifestyle, being socially connected and sleeping well are not often mentioned together,” Chen said. 

“Yet sleep, just like physical activity and diet, can have significant impacts on our health outcomes, and is profoundly affected by our everyday social life. To promote sleep health we must consider a comprehensive approach that emphasizes the role of engaging in our communities, as well as getting enough and better sleep.”

The study “Social Participation and Older Adults’ Sleep” was published in the Journal of Social Science and Medicine. Chen collaborated with Diane Lauderdale and Linda Waite at the University of Chicago on the study. The research was supported by the National Institute of Aging (R01AG042164 and R37AG030481) and the Basic Behavioral and Social Sciences Research Opportunity Network National Institutes of Health.