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Seniors moving to HCBS face more hospital risk

PROVIDENCE, R.I. [Brown University] Seniors want greater access to home- and community-based long-term care services. Medicaid policymakers have been happy to oblige with new programs to help people move out of expensive nursing homes and into cheaper community or home care. It seems like a "win-win" to fulfill seniors' wishes while also saving Medicaid programs money, but a new study of such transitions in seven states finds that the practice resulted in a 40 percent greater risk of "potentially preventable" hospitalizations among seniors dually eligible for Medicaid and Medicare.

"We are trying to move people into the community and I think that is a really great goal, but we aren't necessarily providing the medical support services that are needed in the community," said Andrea Wysocki, a postdoctoral scholar in the Brown University School of Public Health and lead author of the study published online in the Journal of the American Geriatrics Society. "One of the policy issues is how do we care for not only the long-term care needs when we move someone into home- and community-based settings but also how do we support their medical needs as well?"

Wysocki said her finding of a higher potentially preventable hospitalization risk for seniors who transitioned to community- or home-based care suggests that some medical needs are not as well addressed in community settings as they are in nursing homes. More vigilant and effective treatment for chronic, already-diagnosed ailments such as chronic obstructive pulmonary disease could prevent some of the hospitalizations that occur.

There are two likely reasons why care in home and community settings is not as effective in preventing hospitalizations, Wysocki said. Nursing homes provide round-the-clock care by trained nurses and doctors, but workers with much less medical training provide community- and home-care services. In addition, while Medicaid pays for long-term care, Medicare pays for medical care, meaning that Medicaid programs do not have a built-in financial incentive to prevent hospitalizations. Home- and community-based care is less expensive for Medicaid regardless of the medical outcome.

Careful comparison

Wysocki performed the analysis for her doctoral thesis work at the University of Minnesota. She and her co-authors looked at a set of records provided by the Centers for Medicare and Medicaid Services of thousands of dually eligible seniors from Arkansas, Florida, Minnesota, New Mexico, Texas, Vermont, and Washington who entered nursing homes between 2003 and 2005.

Based on those records, Wysocki and her team determined who made the transition to community and home care and who stayed in the nursing home. Accounting for a wide variety of demographic and medical factors, they then compared the rate of hospitalizations among 1,169 seniors who transitioned to the community ("transitioners") and 1,169 otherwise similar seniors who stayed in the nursing home ("stayers").

What Wysocki observed was that 133 transitioners ended up hospitalized for potentially preventable reasons, while only 113 stayers did. Including "non-preventable" hospitalizations, the numbers rose to 419 among transitioners and 297 among stayers.

Those raw numbers don't quite tell the whole story in comparing overall hospitalization risk, however, because seniors in the stayers group also generally took a longer time to reach that first hospitalization than seniors in the transitioners group. Using a standard statistical technique to account for the time difference, Wysocki found that transitioners faced a 40-percent greater risk of enduring a potentially preventable hospitalization and a 58-percent greater risk of any kind of hospitalization than the stayers did.

Making care less fragmented

The study, published Jan. 2, 2014, concludes with a clear recommendation: "Ensuring that an individual has long-term care and medical providers and a care plan at the time of transition may keep them out of the hospital and result in more successful long-term outcomes."

Whether that happens is ultimately up to the payers, Medicaid and Medicare. Wysocki said demonstration programs in which the two programs work in concert, rather than separately to address the issue are underway and merit watching.


Contact: David Orenstein
Brown University

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