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Frequently Asked Questions for RFA-AG-23-024: Policy and Alzheimer’s Disease (AD) and Alzheimer’s Disease-Related Dementias (ADRD) Healthcare Disparities: Access, Utilization, and Quality (R01 Clinical Trial Not Allowed)

Funding Opportunity RFA-AG-23-024

1. What is the overall goal of this Funding Opportunity Announcement (FOA)?

The goal of this FOA is to exploit variations (e.g., geographic, temporal) in social and health care policies to employ experimental, quasi-experimental, or other innovative approaches to uncover mechanisms driving disparities in care (i.e., access, utilization, and quality) for persons living with Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD). Research supported through this announcement will expand the evidence base for policymakers and other decision makers seeking to mitigate these disparities, including disparities affecting individuals living with dementia in the community, in assisted living facilities, or nursing homes.

2. What are the research objectives?

This FOA invites research applications examining how policies (i.e., modifiable actions of public or private institutions) influence disparities in access, utilization, and quality of AD/ADRD health care. Applications should propose research that will examine how policies across settings (i.e., the community, assisted living facilities, nursing homes, hospice) contribute to health disparities in AD/ADRD care. Proposed research must address populations that experience health care disparities and inequities. Investigators are encouraged to refer to the NIA Health Disparities Framework, a multilevel life course disparities conceptual framework, for a list of priority populations (e.g., ethnicity, gender, age, race, disability status, identity, rurality, nativity) for the study of health disparities.

3. Are applications required to incorporate methods for causal inference? 

Yes. Applications must clearly describe the methods that allow for the testing of potential causal relationships, specifically, the causal drivers of health care disparities (e.g., policy as a driver). Creative methodological approaches that capitalize on policy variation (across time, place, etc.) are encouraged and might include quasi-experimental designs, propensity score matching, predictive modeling, geospatial modeling, qualitative inquiry, and innovative use of data linkage and big data (e.g., Centers for Medicare and Medicaid Services [CMS] data).

4. What types of health and health care outcomes are relevant to disparities in access, use and quality of care?

Relevant outcomes could fall under three broad categories: use of medical care, availability of community-based care and services, and community level public health metrics. Outcomes may include: financial strain for patients and families, having a usual source of medical care for those living with dementia, premature nursing home admissions for PLWD, and impacted caregiver well-being. Rates of, and access to, preventive visits and services for those living with dementia is also a valuable outcome, as is the ability to capture emergency department visits and unnecessary hospitalization, quality in overall nursing home care, rates of dementia screening, and family visits in nursing homes and assisted living. Self-rated health of PLWD and their caregivers, and outcomes that matter to those individuals, can also be assessed.

5. What are example research questions relevant to this initiative?

Research questions may include, but are not limited to, the following:

  • How have policies intended to expand access to care (e.g., the Affordable Care Act, Medicaid expansions, etc.) or other changes in health care policy impacted health care access and utilization for those living with AD/ADRD versus those without AD/ADRD? Have these policies influenced disparities in health care access and utilization for those with AD/ADRD?

  • When do changes in health care utilization (level or type) lead to care improvements and for whom? What explains such disparities?

  • Has modification in service provision (e.g., telemedicine) expanded access to services for those living with AD/ADRD and do these alternative modes of service differentially improve outcomes for certain types of patients? Has this modification in service provision led to decreased or increased disparities? Do these alternative modes of service differentially affect outcomes for patients by race/ethnicity, socioeconomic status, sexual and gender minorities (SGM), etc.?

  • Some nursing home patient populations include a high fraction of patients with dementia, while others have relatively limited numbers of dementia patients. What drives these differences in the patient populations? Do nursing homes with large dementia patient populations provide better care to those living with AD/ADRD? What payment, wage, or other policies drive these differences in patient populations? Are there policy drivers that explain racial/ethnic, socioeconomic, SGM, or other differences in nursing home patient populations?

6. What are some policy changes of interest?

Proposed research must utilize "policy" as defined in this FOA to study disparities in AD/ADRD care. Policy changes of interest include, but are not limited to, the following:

  • Changes to CMS’s Annual Wellness visits and billing codes

  • CMS telehealth policy changes before and during the COVID-19 pandemic

  • State-level changes to Long Term Services and Supports (LTSS) coverage and practice (e.g., Oregon, Massachusetts, Wisconsin)

  • Changes in policies to meet CMS’s home and community-based settings rule

  • Provisions of the ACA (e.g., extension of Money Follows the Person demonstration)

  • Changes to Home and Community Based Services (HCBS) waiver waiting lists

  • Changes to visitation policies in nursing homes, assisted living, and hospice facilities

  • Value-based payment for HCBS

  • Policies that impact direct care worker hours across settings

  • Appendix K waivers to respond to emergencies

7. What types of applications would be considered non-responsive?

The following types of applications will be considered non-responsive, and will be withdrawn prior to review:

  • Applications proposing purely descriptive research or the simple enumeration of disparities without incorporating methods for causal inference

  • Applications proposing clinical trial development

  • Applications that do not focus on AD/ADRD populations and research

  • Applications that do not address populations that experience health care disparities and inequities

  • Applications that do not utilize “policy” as defined in this FOA to study disparities in AD/ADRD care

8. Are there any resources I can reference while developing my application?

Yes. Please reference the below resources.

9. When are applications due?

There is a single receipt date: October 20, 2022. No late applications will be accepted (try to submit the application a few days prior to the deadline so that you can make changes, if needed).

10. When is the earliest start date?

The earliest grant start date is July 2023.

11. How many projects will be funded?

NIA intends to commit $4,500,000 in fiscal year 2023 to fund 5-6 awards. Application budgets are limited to $500,000 per year in direct costs and need to reflect the actual needs of the proposed project. The maximum project period is 5 years.

12. Is a letter of intent required?

A letter of intent is not required, is not binding, and does not enter into the review of a subsequent application, but the information that it contains allows staff to estimate the potential review workload and better plan the review.

By September 20, 2022, prospective applicants are asked to submit a letter of intent that includes the following information:

  • Descriptive title of proposed activity

  • Name(s), address(es), and telephone number(s) of the PD(s)/PI(s)

  • Names of other key personnel

  • Participating institution(s)

  • Number and title of this funding opportunity

A letter of intent should be sent to:

Elena M. Fazio, Ph.D.
National Institute on Aging (NIA)
Telephone: 301-496-3136
Email: Elena.Fazio@nih.gov

13. Are foreign institutions eligible to apply?

Non-domestic (non-U.S.) Entities and Non-domestic (non-U.S.) components of U.S. Organizations are eligible to apply.

Foreign components, as defined in the NIH Grants Policy Statement, are allowed.

14. Who should I contact if I have further questions?

Investigators are highly encouraged to contact Dr. Fazio during the planning stages of an application.

Elena Fazio, Ph.D.
National Institute on Aging (NIA)
Telephone: 301-496-3136
Email: elena.fazio@nih.gov

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