Advancing Healthcare for Older Adults from Populations that Experience Health Disparities

The U.S. older adult (those aged 65 and over) population is rapidly growing and becoming more diverse. By year 2060, it is projected that nearly half of this population will be comprised of persons from racial and/or ethnic minority populations. Older adults from populations that experience health disparities are more likely to report poorer physical health, mental health, and quality of life. They also tend to have more coexisting health conditions including cognitive impairment and functional limitations, less access to timely diagnosis and optimal quality of care, and experience more hospital admissions, readmissions, and multiple care transitions. Furthermore, disparities in health and healthcare continue to persist among these populations and were magnified during the COVID-19 pandemic. Therefore, the current U.S. health care systems and workforce’s lack of preparedness to meet the challenges of caring for older adults, especially those from populations that experience health disparities is a serious public health and societal concern.

There is ample research evidence indicating that there are many factors that may lead to omissions and commissions of care for older adults that often result in preventable adverse outcomes including delays in or over-screening, missed or delayed diagnoses, and untimely treatment or over-treatment. Such factors include ageism, mistreatment, delivery of substandard care, errors in clinical judgement, providing care that may do more harm than good, and dismissal of health concerns by healthcare providers and/or caregivers. All of these can negatively affect the physical and mental health of older adults and co-occur with other forms of discrimination (e.g., racism).

In addition, making a correct and timely diagnosis and care plan for older adults is a process influenced by a myriad of factors that can influence screening and diagnostic tests’ performance and accuracy. Some of these include:

• Underrepresentation of older adults, especially those over the age of 75, in clinical research.
• Age-dependent variations in sensitivity and/or specificity of screening and/or diagnostic tests.
• Screening tests for which diagnostic and/or treatment benefit is unclear after a certain age, or within the context of health status, quality of life, and/or projected life expectancy.
• Screening tests recommendations that consider patient preferences and weigh benefits versus risks/ harms.
• Symptoms and signs that are different from the clinical profiles observed in younger populations.
• Delayed recognition of health conditions by patients and caregivers/family members due to attribution of symptoms as part of the normal aging process.
• Family dynamics, built environment, and sociocultural environment factors that influence optimal care and quality of life.
• Diagnostic protocols or guidelines that create gaps in care delivery.
• Diagnostic, treatment, and continuity of care complexities associated with multiple coexisting chronic conditions.
• Side effects and adverse events associated with complex pharmacological therapy.
• Unfamiliarity or lack of proficiency in key cultural factors across different levels in the healthcare continuum and across various stages of the aging continuum.
• Limited health system resources and infrastructure, and health care policies that may limit coverage eligibility or access to optimal care and health equity.
• Lack of shared decision-making that is guided by principles of aging with dignity, self-determination, and autonomy.

Well synchronized care coordination within and across care teams and care settings can mitigate health disparities in older adults. For example, well-coordinated in-home health care can allow individuals to remain living at home and maintain their independence by receiving care and support from a family caregiver or home health aide. Also, transitional care interventions for older adults are associated with reductions in preventable hospital and emergency room readmissions. On the other hand, many in-home caregivers may not be trained to properly handle the complex demands of providing and coordinating care. In addition, the effectiveness of care coordination may be impaired by the fragmentation of care, and breakdowns in coordination, communication, and collaboration processes between care team members, including the older adults and caregivers. These could result in delayed or missed diagnoses and timely treatment. Furthermore, interventions on care coordination involving in long-term care, palliative and/or end-of-life care settings -where most hospice care takes place-, and for patients from populations that experience health disparities are sparse.

Hence, crucial research gaps remain for improving the prevention, diagnosis, and treatment for many health conditions that burden older adults from populations that experience health disparities. Similarly, novel interventions that explore the role of shared decision-making and care coordination are needed.

Neglect and mistreatment of older adults would be expected to impair the effectiveness of medical care/diagnostic recommendations, care coordination and shared decision making. However, the risk and protective factors associated with mistreatment of older adults from populations that experience health disparities – and interventions to address it- are understudied. Therefore, the design, study and/or evaluation of strategies or interventions that address neglect and/or mistreatment within the context of care coordination across care teams, care settings, and agencies (e.g., protective services, home health, financial, legal services, housing) of older adults from populations that experience health disparities is another crucial research gap to be filled.

Research Objectives:

In addition to the goals stated under the Purpose, the overarching aim of this NOFO is to identify and understand best practices to engage older adults and their caregivers in providing appropriate care that is central to the attainment of optimal physical and mental health and wellbeing of older adults and the reduction of health disparities in this population.

Projects should focus on one or more NIH-designated health disparity populations living in the 50 states, the District of Columbia, Tribal Nations, and the U.S. territories. Projects that focus on racial and ethnic minority populations and/or low socioeconomic status (SES) persons are of particular interest. For all other categories, projects that explore the intersectionality of age, sex, race, and ethnicity and/or low SES with rural populations or SGM groups, and people with disabilities are encouraged. Applications proposing approaches which consider multi-level determinants of health (e.g., patient, clinician, health care system, community) to address health disparities while optimizing the health and well-being of older adults from populations that experience health disparities are encouraged. Please refer to the NIMHD Research Framework for additional detail. Applications that plan to collect primary data from older adults, caregivers, clinicians and other persons are strongly encouraged to use the measures on social determinants of health in the PhenX tool kit.

This initiative will support research in outpatient, inpatient, institutional-based long term care settings, home-based care, and emergency care facilities serving diverse older adults. In addition, research that involves a partnership with relevant agencies (such as area agencies on aging, state units on aging, senior services, advocacy organizations for older adults, faith-based services) that offer home and community-based services for the older adult such as home-delivered meals, case management, companionship programs, are welcome. Outpatient settings include primary care, specialty clinics and specialty care settings such as dialysis or chemotherapy centers. Inpatient and institutional long-term care settings include hospitals, assisted living facilities, skilled nursing facilities, and long-term chronic care institutions. Research within the context of transitional care (e.g., hospital to home, or rehabilitation to home), palliative care, end-of-life care, and long-term care, where patients interact with clinicians on a regular basis, is also of interest. Studies may involve in-person and/or telemedicine encounters. This initiative is not solely focused on clinical health outcomes. Research on intermediary measures of non-clinical outcomes (e.g., trust, self-efficacy, self-autonomy, empowerment, safety, and resilience) are of interest.

Research Methodology

This NOFO seeks to support descriptive studies, interventions (especially multi-component, multi-sectoral, and/or or multi-level interventions), clinical trials (including cluster-randomized trials, and pragmatic trials), quasi-experimental studies, natural experiments (e.g., impact of policy), quality improvement studies, mixed methods research, and simulation modeling. Projects focused on rural populations, SGM groups, and people with disabilities are encouraged to examine intersections with race and/or ethnicity, and SES. Comparison groups/populations may also be included as appropriate for the research questions posed. It is expected that lessons learned from this initiative can help build research evidence regarding approaches to improve health outcomes for older adults from populations that experience health disparities.

Specific Areas of Research Interest

NIMHD areas of research interests include but are not limited to the following:

Optimization of screening, diagnostic and clinical care guidelines for commonly experienced conditions

• Addressing gaps in timely assessment, diagnosis, and treatment of highly prevalent conditions (infectious and chronic non-communicable conditions) and coexisting conditions in this population. This may include:
  • Establishing or modifying diagnostic criteria or identifying phenotypes that may be different in older adults.
  • Developing and/or tailoring, testing, and evaluating existing tools to assess symptom burden, quality of life, and/or function, or implementing diagnostic and care guidelines that are adaptable to this population.
• Studies that seek to understand optimal practices for the recommendation of screening tests and assessments while considering tradeoffs of harm (e.g., false-positives, over-diagnosis) and benefits (e.g., quality of life) as well as optimal time for screening (e.g., intervals, stopping age) and discontinuation of screening.

Shared medical decision-making to enhance care planning and patient agency.

• Studies that explore the concept of shared decision-making between clinicians/care team and the older adult and their caregiver(s). These may include:
  • Addressing conflicting recommendations for care as well as balancing clinician recommendations, patient preferences, and caregiver perspectives regarding harms, benefits, and outcomes. This may include point of care interventions that incorporate clinical decision support (CDS) within electronic health records (EHRs).
  • Considering patient agency and the legal aspects and cultural norms of decision making (e.g., advance directives), especially within the context of major junctions in care, like invasive procedures, aggressive therapy with significant adverse reactions, or treatment or procedures for which there is insufficient prognostic evidence in older adults.
• Developing, testing and/or evaluating interventions in the health care settings that mitigate ageism, racism, and/or other forms of discrimination, prejudices, and stereotypes against older adults.
• Developing, testing and/or evaluating culturally tailored interventions that strengthen care settings and/or their workforce to care for older adults while being responsive to their diverse racial, ethnic, cultural, religious, social, economic, and geographical backgrounds.
• Developing, testing and/or evaluating culturally tailored interventions designed to facilitate coordination of legal assistance for older adults and their effect on strengthening patient agency, improving shared decision making, and in preventing financial exploitation.

Effective strategies for coordinating care for older adults from populations that experience health disparities.

• Developing, testing and/or evaluating care coordination strategies. These could address:
  • Challenges or breakdowns in the diagnostic and care pathways from one care setting or level to another.
  • Multiple care transitions to and from the home, care facilities, palliative care, and end-of-life care settings.
  • Care team functioning (e.g., communication), including the role of geriatric case managers and care coordinators.
  • Care setting infrastructures (e.g., coordination tools) to optimize care delivery both within and across care teams (including the patient and caregivers/family), care settings, and other agencies involved in meeting the needs of older adults.
• Evaluating the effect of policies that may drive health care disparities in older adults (e.g., affordable care, expanded coverage, drug pricing, health care accessibility and financing) on the effectiveness of optimal care coordination and health outcomes.
• Studies that evaluate the role or effect of neglect, mistreatment and/or exploitation of older adults and established policies to protect them on the effectiveness of care coordination and other healthcare-based strategies.

Specific Areas of Research Interest for Participating Organizations:

National Cancer Institute (NCI)

NCI is interested in studies that will advance the development and implementation of innovative healthcare strategies across the cancer care continuum for older adults from populations that experience health disparities. Research areas of interest to NCI include, but are not limited to:

• Increasing the integration and uptake of validated assessments (e.g., geriatric assessment, cognitive/physical function assessment) as well as refining and tailoring measures for specific older adult populations that experience health disparities to evaluate symptom burden, quality of life, and/or function across the cancer care continuum. Recommendations for discontinuation of screening tests should consider tradeoffs of harm and benefits as well as the optimal time for screening discontinuation or for extending the interval between repeat surveillance testing.
• Enhancing patient-centered communication and shared decision-making processes that are personalized to the values and preferences for care, quality of life, and independence of older adults and their families. This may include the development or cultural tailoring of communication approaches (e.g., decision aids) and efforts to balance the preferences for care and trade-offs of screening, diagnosis, cancer treatment, and end-of-life care for older adults from populations that experience health disparities.
• Understanding and supporting caregiving for older adults with cancer, including care training, promote coping skills, and care management across diverse healthcare settings. Tailored or adapting caregiving interventions that target medically underserved and underrepresented patient populations are of interest.
• Understanding and improving teamwork and coordination of comprehensive care for older adults from populations experiencing health disparities across the cancer care continuum, particularly as it relates to the management of multiple chronic conditions and during transitions in care from specialist to primary care. This may include healthcare delivery related factors, such as organizational readiness/capacity, teamwork processes, and care delivery approaches (i.e., in-person/telehealth), as well as communication of survivorship care planning and navigation of care and services tailored to older adult cancer survivors.
• Understanding and addressing barriers to equitable cancer care among older adults from populations experiencing health disparities, especially as it relates to ageism, digital divide, and access to cancer screening, diagnosis, treatment, survivorship care, palliative care, and end-of-life care.
• Examining the use of patient-reported outcomes (PROs) to stratify risk, support decision-making, and optimize cancer outcomes specific for older adult cancer survivors from populations that experience health disparities.
• Addressing the rehabilitation needs of older adults before, during, and after cancer treatment to reduce the adverse impacts from cancer treatment and to increase cognitive, functional, physical, and psychological resilience.
• Addressing the integration of social care into clinical care through the design and testing of interventions that adjust care to the personalized social needs of the older adult cancer survivor as well as connect and coordinate with social care services and resources. Examples include addressing poverty, food insecurity, housing instability, transportation-related barriers, employment-related impacts, and social isolation/loneliness to optimize the delivery of quality cancer care and improve health outcomes for older adults.
• Identifying strategies to increase representation of older adults from populations that experience health disparities in studies of cancer survivorship.
• Understanding and addressing the divide in access to and use of digital health tools and interventions where technology, online, digital, and mHealth components of interventions (e.g., PROs portals, decision aids, telehealth) can act as barriers to care and further exacerbate health disparities.

National Institute of Nursing Research (NINR) 

The National Institute of Nursing Research (NINR) supports research aligned with our mission and strategic priorities, conducted by scientists from any discipline. NINR discovers solutions to health challenges through the lenses of health equity, social determinants of health, population and community health, prevention and health promotion, and systems and models of care. Drawing on the strengths of nursing’s holistic, contextualized perspective, core values, and broad reach, NINR funds multilevel and cross-sectoral research that examines the factors that impact health across the many settings in which nurses practice, including homes, schools, workplaces, clinics, justice settings, and the community.

National Institute on Aging (NIA)

The mission of NIA is to support and conduct genetic, biological, clinical, behavioral, social, and economic research on aging; foster the development of research and clinician scientists in aging; provide research resources; and disseminate information about aging and advances in research to the public, health care professionals, and the scientific community, among a variety of audiences. Work should be guided by the NIA Health Disparities Framework and intervention development aligned with the NIH Stage Model for Behavioral Intervention Development and Science of Behavior Change.

NIA supports research that involves primary data collection as well as secondary data analysis.

NIA areas of research interests related to older adults from minoritized populations include, but are not limited to, the following:

• Clinical Care for Older Adults: Improving diagnostic and clinical care guidelines for older adults from minoritized populations experiencing health disparities.
• Interventions to Ameliorate Health Disparities in Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD): Research to address health inequities, including prevention, detection, and treatment of AD/ADRD.
• Shared Decision-Making: Enhancing shared decision-making between clinicians, care teams, older adults, and their caregivers to improve communication, care planning, and decision-making tools. NIA is especially interested in Shared Decision-Making in Palliative Care.
• Care Coordination: Focus on addressing care coordination challenges for persons with multiple chronic conditions and across various care settings and transitions, aiming to mitigate delayed or missed diagnoses and treatments.
• Interventions that test approaches to reduce interpersonal bias and discrimination in health care settings. Developing and assessing interventions to mitigate ageism, racism, and other forms of bias and discrimination based on stereotypes against older adults. Encouraging research focused on identifying sources of bias and discrimination, considering both individual and institutional levels. Elucidating the types of cognitive biases that can occur, such as confirmation bias, anchoring bias, etc., in interpersonal interactions. Highlighting the contexts in which these biases arise, including clinical decision-making, diagnostic biases, and consideration/presentation of treatment options.
• Evaluating existing methods and developing new strategies for health-system based interventions to prevent, recognize, and address various forms of elder mistreatment, including physical, sexual, emotional, or psychological abuse; neglect; abandonment; and financial or material exploitation. RFA-AG-24-048 contains a more comprehensive description of NIA’s interest in this area.
• Developing and evaluating interventions to achieve equity in access to and receipt of palliative care for medically underserved older adults and their caregivers at the time of diagnosis or during treatment.

Office of Disease Prevention

Ofice of Disease Prevention (ODP): The ODP is the lead office at the NIH responsible for assessing, facilitating, and stimulating research in disease prevention. In partnership with the 27 NIH Institutes and Centers, the ODP strives to increase the scope, quality, dissemination, and impact of NIH-supported prevention research. The ODP provides co-funding support for research that has strong implications for disease and injury prevention, health equity, and research that includes innovative and appropriate research design, measurements, and analysis methods.

The ODP does not award grants; therefore, applications must be relevant to the objectives of at least one of the participating NIH ICs listed in this announcement. The ODP only accepts co-funding requests from NIH ICs. For questions regarding IC research and/or funding priorities, be sure to contact the relevant IC Scientific/Research Contact(s) named in this NOSI. For additional information about ODP, please refer to the ODP Strategic Plan or visit prevention.nih.gov.

Applications Not Responsive to the NOFO:

• Studies without a focus on racial and ethnic minority populations and/or SES disadvantaged persons or the intersection with other populations that experience health disparities.
• Studies focused on accelerated or accentuated aging in people less than age 65. For example, in people living with HIV, individuals with a disability, etc.
• Research that is exclusively qualitative.
• Projects that test interventions that do not involve more than one level of influence.
• Projects that prospectively test evidence-based interventions without modifications to the intervention content, delivery, or implementation specific to older adults from population that experience health disparities.
• Projects focused solely on the training of the health care workforce without understanding its impact on older adults from populations that experience health disparities or measuring outcomes that matter to this population of older adults.
• Projects that examine the financing of health care or the cost and efficiency of health care service delivery, without linking such economic analysis to measurable health outcomes (See NOT-OD-16-025 for more information).

Investigators proposing NIH-defined clinical trials may refer to the Research Methods Resources website for information about developing statistical methods and study designs.