Medicaid home‐ and community‐based services and discharge from skilled nursing facilities

Abstract

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.

Unmet Needs for Help With Mobility Limitations Among Older Adults Aging in Place: The Role of Rurality

“…For the 11% of rural older adults and 7% of urban older adults aging in place who do have unmet mobility needs; however, our findings may reflect being stuck in place, rather than aging in place because of preference. Policy and programs need to become more attuned to that nuance (Chen et al, 2019; Friedman et al, 2019; Gorges et al, 2019; Wang et al, 2021). This means that, while substantial gains have been made in ensuring that older adults are able to remain in their homes and communities, effort still needs to be put into ensuring high-quality alternatives to aging in place, especially in rural areas (Henning-Smith, Mulcahy, et al, 2021).…”

Higher levels of state funding for Home‐ and Community‐Based Services linked to better state performances in Long‐Term Services and Supports

“…Current evidence on such an impact is limited and mixed, with existing studies frequently focused on a single LTSS outcome. Two studies suggested a positive association between higher proportion of state Medicaid LTSS spending on HCBS and successful community discharge of NH patients, 5,6 whereas another study employing a different dataset found no association 7 . Additionally, Medicaid HCBS recipients in states with more generous HCBS policies had a lower risk of long‐term NH admission 8,9 and lower depression rates, 10 but higher rates of potentially preventable hospitalizations 11–14 .…”

“…Two studies suggested a positive association between higher proportion of state Medicaid LTSS spending on HCBS and successful community discharge of NH patients, 5,6 whereas another study employing a different dataset found no association. 7 Additionally, Medicaid HCBS recipients in states with more generous HCBS policies had a lower risk of long-term NH admission 8,9 and lower depression rates, 10 but higher rates of potentially preventable hospitalizations. [11][12][13][14] Since the impact of state support on HCBS may vary across outcomes and populations, further research is needed to comprehensively evaluate the effects of such policies on various aspects of LTSS.…”

Home- and Community-based Care in the New Generation of Medicaid Administrative Data

“…(Watts, Musumeci, and Ammula 2022) Medicaid administrative data in its former iteration, MAX, have been used widely to investigate Medicaid HCBS, producing studies at the national and state levels, focusing on a range of research topics including access to care, quality of care, and disparities in HCBS. (Gorges, Sanghavi, and Konetzka 2019; Wang et al 2021;Fabius et al 2018) For study of HCBS, the legacy MAX data offered some advantages. For years, CMS contracted with a research organization, Mathematica Policy Research, to curate the state-supplied data and transform it into a usable national data set.…”