Objective
To examine the relationship between Medicaid home‐ and community‐based services (HCBS) generosity and the likelihood of nursing home (NH) admission for dually enrolled older adults with ...Alzheimer's disease and related dementias (ADRD) and their level of physical and cognitive impairment at NH admission.
Data Sources
National Medicare data, Medicaid Analytic eXtract, and MDS 3.0 for CY2010‐2013 were linked.
Study Design
Eligible Medicare–Medicaid dual beneficiaries with ADRD were identified and followed for up to a year. We constructed two measures of HCBS generosity, breadth and intensity, at the county level for older duals with ADRD. Three binary outcomes were defined as follows: any NH placement during the follow‐up year for all individuals in the sample, high (vs. not high) physical impairment, and high (vs. not high) cognitive impairment at the time of NH admission for those who were admitted to an NH. Logistic regressions with state‐fixed effects and county random effects were estimated for these outcomes, respectively, accounting for individual‐ and county‐level covariates.
Data Extraction Methods
The study sample included 365,310 community‐dwelling older dual beneficiaries with ADRD who were enrolled in fee‐for‐service Medicare and Medicaid between October 1, 2010, and December 31, 2012.
Principal Findings
Considerable variations of breadth and intensity in county‐level HCBS were observed. We found that a 10‐percentage‐point increase in HCBS breadth was associated with a 1.4 (p < 0.01)‐percentage‐point reduction in the likelihood of NH admission. Among individuals with NH admission, greater HCBS breadth was associated with a higher level of physical impairment, and greater HCBS intensity was associated with a higher level of physical and cognitive impairment at NH admission.
Conclusions
Among community‐dwelling duals with ADRD, Medicaid HCBS generosity was associated with a lower likelihood of NH admission and greater functional impairment at NH admission.
Objective
To examine the association between the generosity of Medicaid home‐ and community‐based services (HCBS) and the likelihood of community discharge among Medicare‐Medicaid dually enrolled ...older adults who were newly admitted to skilled nursing facilities (SNFs).
Data Sources
National datasets, including Medicare Master Beneficiary Summary File (MBSF), Medicare Provider and Analysis Review (MedPAR), Medicaid Analytic eXtract (MAX), minimum data set (MDS), and publicly available data at the SNF or county level, were linked.
Study Design
We measured Medicaid HCBS generosity by its breadth and intensity and described their variation at the county level. A set of linear probability models with SNF fixed effects were estimated to characterize the association between HCBS generosity and likelihood of community discharge from SNFs. We further stratified the analyses by the type of index hospitalizations (medical vs surgical events), age group, and the Medicaid cost‐sharing policy for SNF services.
Data Extraction Methods
The final analytical sample included 224 229 community‐dwelling dually enrolled older duals who were newly admitted to SNFs after an acute inpatient event between October 1, 2010, and September 30, 2013.
Principal Findings
We observed substantial cross‐sectional and over‐time variations in HCBS breadth and intensity. Regression results indicate that on average, a 10 percentage‐point increase in HCBS breadth was associated with a 0.7 percentage‐point increase (P < 0.01) in the likelihood of community discharge. Such relationship could be modified by individual factors and state policies: significant effects of HCBS breadth were detected among medical patients (0.7 percentage‐point, P < 0.05), individuals aged older than 85 (1.5 percentage‐point, P < 0.01), and states with and without lesser‐of policies (0.5 and 2.3 percentage‐point, respectively, P < 0.05). No significant relationship between HCBS intensity and community discharge was detected.
Conclusions
Higher Medicaid HCBS breadth but not intensity was associated with a greater likelihood of community discharge, and such relationship could be modified by individual factors and state policies.
Objective
To assess governmental and nongovernmental stakeholders' perceived impacts of a Medicaid home‐ and community‐based services (HCBS) rebalancing initiative, the Balancing Incentive Program ...(BIP).
Data Sources
Governmental stakeholders (Medicaid administrators) and nongovernmental stakeholders (service providers and consumer advocates) (n = 30) from eight states that participated in BIP.
Study Design
We conducted key informant interviews.
Data Collection
Interviews followed a semi‐structured guide and were professionally transcribed. We thematically coded transcripts using an iterative codebook with a priori and emergent codes.
Principal Findings
Stakeholders reported that BIP participation had a range of impacts on the HCBS ecosystem, often beyond the mandated structural reforms. BIP activities were believed to have changed the culture of HCBS in some states, for example, at the level of state administration or in the provision of HCBS to consumers. Stakeholders also described significant improvements in cross‐stakeholder relationships and communication, for example, in the context of troubleshooting consumers' unmet needs or improvements in the states' responsiveness to providers' inquiries. Stakeholders believed that within‐state data harmonization undertaken through Core Standardized Assessment (CSA) was a positive impact of BIP, particularly with regard to its utility for administrative data, care planning, and patient‐centeredness. Two stakeholders also voiced concerns regarding the validity of spending‐based rebalancing metrics. The impacts that stakeholders attributed to BIP may help create a more sustained rebalancing environment through their changes to the ecosystem, including infrastructure upgrades, data harmonization, collaboration across stakeholders and agencies, more patient‐centeredness, and greater recognition of HCBS.
Conclusions
Our findings highlight additional BIP impacts to monitor over the longer term and to consider in evaluations of future rebalancing efforts. Some potential impacts of BIP are more readily quantified (e.g., HCBS spending), while others are less likely to be formally assessed (e.g., improved stakeholder cooperation). These latter impacts are likely instrumental to future rebalancing efforts.
Objectives
Beneficiaries dually eligible for Medicare and Medicaid are of increasing interest because of their clinical complexity and high costs. The objective of this study was to examine the ...incidence, costs, and factors associated with potentially avoidable hospitalizations (PAH) in this population.
Design
Retrospective study of hospitalizations.
Setting
Hospitalizations from nursing facilities (NF) including Medicare and Medicaid‐covered stays, and Medicaid Home and Community‐Based Services (HCBS) waiver programs.
Participants
Dually eligible individuals who received Medicare skilled nursing facility (SNF) or Medicaid NF services or HCBS waiver services in 2005.
Interventions
None.
Measurements
Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated Diagnostic Related Groups (DRGs) which can often be prevented or safely and effectively managed without hospitalization.
Results
More than one‐third of the population was hospitalized at least once, totaling almost 1 million hospitalizations. The admitting DRG for 382,846 (39%) admissions were identified as PAH. PAH rates varied considerably among states, and blacks had a higher rate and costs for PAH than whites. Five conditions (pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease/asthma) were responsible for 78% of the PAH. The total Medicare costs for these hospitalizations were $3 billion, but only $463 million for Medicaid. A sensitivity analysis, assuming that 20%–60% of these hospitalizations could be prevented, revealed that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided annually in this population.
Conclusion
Potentially avoidable hospitalizations are common and costly in the dually eligible population. New initiatives are needed to reduce PAH in this population as they are costly and can adversely affect function and quality of life.
Objective
To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home‐ and community‐based services (HCBS) after the 2001 Millennium Act significantly changed ...Veterans' utilization of institutional, paid home, and unpaid home care relative to a non‐VHA user Medicare population that was not exposed to HCBS expansion efforts.
Data Sources
We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012.
Study Design
We conducted a retrospective‐matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference‐in‐differences approach with a person fixed‐effects estimator.
Data Collection/Extraction Methods
Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services.
Principal Findings
Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long‐term care (0.7% points, 95% CI: −0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: −0.011, 0.0125). VHA users received more hours of unpaid care post‐Millennium Act (1.48, 95% CI: −0.232, 3.187), though this effect was not significant once we introduced controls for mental health.
Conclusions
Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.
Few studies have assessed the impact of home and community‐based services (HCBSs) provision on cognitive function among older adults over time. This study examined the longitudinal association ...between HCBSs provision and cognitive function in Chinese older adults. The study included 5,134 participants aged 65 years and older in the Chinese Longitudinal Healthy Longevity Survey from 2008 to 2014. The Mini‐Mental State Examination (MMSE) was used to evaluate cognitive function over the same time period. Participants were asked what kind of HCBSs were provided in his or her community. However, they were not asked whether services were utilised. The study used the number of HCBSs provided each wave to represent the strength of HCBSs, and used the MMSE score of each wave to represent the older adults’ cognitive function status. A latent growth model was used to explore the relationship between HCBSs provision and cognitive function of older adults. The number of HCBSs provided was positively associated with older adults’ cognitive function (2008: β = 0.03, p = 0.031; 2011: β = 0.06, p < 0.001; 2014: β = 0.06, p < 0.001) after controlling for gender, age, residence, education, income, medical insurance, activities of daily living disability, instrumental activities of daily living disability, serious illness, living arrangement and marital status. Results provided longitudinal evidence that an increase in HCBSs provision at a national level can result in better cognitive function in Chinese older adults.
Introduction
In response to COVID‐19, national ministries of health adapted HIV service delivery guidelines to ensure uninterrupted access to antiretroviral therapy (ART) and limit the frequency of ...contact with health facilities. In this commentary, we summarize four ways in which differentiated service delivery (DSD) for HIV treatment has been accelerated during COVID‐19 in policy and implementation in sub‐Saharan Africa (SSA) – (i) expanding eligibility for DSD for HIV treatment, (ii) extending multi‐month dispensing (MMD) and reducing the frequency of clinical consultations, (iii) emphasizing community‐based models and (iv) integrating/aligning with TB preventative therapy (TPT), non‐communicable disease (NCD) treatments and family planning commodities.
Discussion
Across SSA in 2020, countries both adapted and emphasized policies supporting DSD for HIV treatment in response to COVID‐19. Access to DSD for HIV treatment was expanded by reducing the time required on ART before eligibility and being more inclusive of specific populations including children and adolescents, pregnant and breastfeeding women and those on second‐ and third‐line regimens. Access to extended ART refills, or MMD, was accelerated across many countries. A renewed focus was given to out‐of‐facility community‐based models of ART distribution. In some settings, there was acknowledgement of the need to integrate or align other chronic medications with ART.
Conclusions
Adaptations to DSD for HIV treatment in response to COVID‐19 have resulted in rapid policy change and in some cases, acceleration of implementation in SSA. As the COVID‐19 pandemic evolves, there is a critical need to assess the impact of these adaptations and, where beneficial, ensure that policies implemented in response to COVID‐19 become the new normal.
To examine the potential benefit of home-delivered meals for reducing frailty levels among community-dwelling older adults at risk for malnutrition.
A retrospective, single-group observational ...approach.
One large home-delivered meal agency in the Midwest United States.
1090 community-dwelling older adults who received home-delivered meal services, funded through the Older Americans Act, between June 2020 and December 2021.
Frailty status was measured by the Home Care Frailty Scale (HCFS) which was routinely administered by agency staff to home-delivered meal clients as part of a quality improvement project. The HCFS was administered at the start of meal services, 3-months after meals began, and 6-months after meals began.
At baseline, 55.4% of clients were found to be at high risk for malnutrition. While there was a significant and consistent decline in HCFS throughout the follow-up period for both high and low nutritional risk groups, the reduction in frailty from baseline to 6-months was greater for the high nutritional risk group (Δ = −1.9; 95% CI: −2.7, −1.1; p < 0.001) compared to those with low nutritional risk (Δ = −1.5; 95% CI: −2.3, −0.7; p < 0.001). Compared to those who lived alone, clients who lived with other individuals presented with higher levels of frailty at baseline and 3-month follow-up for both low and high malnutrition risk groups.
Home-delivered meal clients are commonly at risk for both frailty and malnutrition. Home-delivered meal programs, which are intended to reduce malnutrition among older adults, may serve as a promising solution for reducing frailty in the vulnerable aging population.
Objective
To examine the relationship between the level of state funding for Home‐ and Community‐Based Services (HCBS) and state overall and dimension‐specific performances in Long‐Term Services and ...Supports (LTSS).
Data Sources and Study Setting
We employed state‐level secondary data from the Medicaid LTSS Annual Expenditures Reports, the American Association of Retired Persons (AARP) State Scorecards, the U.S. Census, and Federal Reserve Economic data, spanning the timeframe of 2010–2020.
Study Design
Overall state LTSS rankings, along with dimension‐specific rankings, were modeled separately against state Medicaid spending on HCBS relative to total Medicaid spending on LTSS. All models were adjusted for state covariates, secular trend, and state fixed effects.
Data Collection/Extraction Methods
The study sample included all 50 states and the District of Columbia. However, California, Delaware, Illinois, and Virginia were excluded from FY2019 due to missing data on Medicaid HCBS expenditures.
Principal Findings
Every 10 percentage‐point increase in the proportion of Medicaid LTSS spending to HCBS demonstrated 2.05 points improvement (95% confidence interval CI: −3.88 to 0.22, p = 0.03) in rankings for state overall LTSS system performance, 2.92 points improvement (95% CI: −4.87 to 0.98, p < 0.01) in rankings for the Choice of Setting and Provider dimension, as well as 1.73 points (95% CI: −3.14 to 0.32, p = 0.02) ranking improvement in the dimension of Effective Transitions.
Conclusions
Our study suggested promising effects of increased state funding for HCBS on LTSS performance.
Few studies have assessed the association between perceived availability of home‐ and community‐based services (HCBSs) and self‐reported depression among Chinese older adults, which the present study ...attempts to rectify. This cross‐sectional study enrolled 11,941 participants aged 65 and older from the Chinese Longitudinal Healthy Longevity Survey 2018 wave. The 10‐item Center for Epidemiologic Studies Depression Scale (CESD‐10) was used to evaluate depression, and perceived availability was measured for four categories of HCBSs: daily life assistance, medical care services, emotional support and social services, and other. These four categories and the number of services in each were used to represent the perceived availability of service provision. Binary logistic models were used to explore the relationship between perceived availability of HCBSs and depression in older adults. Perceived daily life assistance was found to be negatively associated with depression symptoms among Chinese older adults in both urban and rural areas rural: OR (95%CI) = 0.66 (0.55–0.78), p < 0.001; urban: OR (95% CI) = 0.69(0.60–0.79), p < 0.001, while perceived levels of medical care services, emotional support and social services, and other were not associated with depression symptoms in rural or urban areas. Our primary finding was that providing daily life assistance at the community level may help to meet more older adults’ daily needs, thus potentially decreasing the risk of depression.
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