Racial Disparities in Post-Acute Home Health Care Referral and Utilization among Older Adults with Diabetes

Abstract

Racial and ethnic disparities exist in diabetes prevalence, health services utilization, and outcomes including disabling and life-threatening complications among patients with diabetes. Home health care may especially benefit older adults with diabetes through individualized education, advocacy, care coordination, and psychosocial support for patients and their caregivers. The purpose of this study was to examine the association between race/ethnicity and hospital discharge to home health care and subsequent utilization of home health care among a cohort of adults (age 50 and older) who experienced a diabetes-related hospitalization. The study was limited to patients who were continuously enrolled in Medicare for at least 12 months and in the United States. The cohort (n = 786,758) was followed for 14 days after their diabetes-related index hospitalization, using linked Medicare administrative, claims, and assessment data (2014–2016). Multivariate logistic regression models included patient demographics, comorbidities, hospital length of stay, geographic region, neighborhood deprivation, and rural/urban setting. In fully adjusted models, hospital discharge to home health care was significantly less likely among Hispanic (OR 0.8, 95% CI 0.8–0.8) and American Indian (OR 0.8, CI 0.8–0.8) patients compared to White patients. Among those discharged to home health care, all non-white racial/ethnic minority patients were less likely to receive services within 14-days. Future efforts to reduce racial/ethnic disparities in post-acute care outcomes among patients with a diabetes-related hospitalization should include policies and practice guidelines that address structural racism and systemic barriers to accessing home health care services.

Timing of Home Health Care Initiation and 30-Day Rehospitalizations among Medicare Beneficiaries with Diabetes by Race and Ethnicity

“…This was a retrospective analysis of Medicare fee-for-service and Medicare Advantage beneficiaries who experienced a diabetes-related hospitalization in 2015 that ended in discharge to home with a home health care referral or self-care [ 18 ]. Linked datasets utilized for this project include the Medicare Beneficiary Summary File (MBSF) (2014–2016, 100%), the inpatient Medicare Provider and Analysis Review (MedPAR) file, and the Home Health Outcome and Assessment Information Set (OASIS).…”

“…Linked datasets utilized for this project include the Medicare Beneficiary Summary File (MBSF) (2014–2016, 100%), the inpatient Medicare Provider and Analysis Review (MedPAR) file, and the Home Health Outcome and Assessment Information Set (OASIS). The study design, selection of variables, and interpretation of results were guided by our adaptation [ 18 ] of Andersen and Newman’s Framework for Viewing Health Services Utilization ( Figure 1 ) [ 22 ].…”

“…Institutional and structural barriers can cause delayed or missed care. In recent studies of Medicare patients discharged to home health care in 2015–2016, 54% of all hospitalizations [ 17 ] and 73% of patients with a diabetes-related stay [ 18 ] received home health care within two weeks of discharge. Racial/ethnic disparities in post-acute referral and utilization of home health care were observed in both studies for non-Hispanic Black, Asian American/Pacific Islander (AAPI), American Indian/Alaska Native (AIAN), and Hispanic patients compared to (non-Hispanic) WHITE patients [ 17 , 18 ].…”

“…In recent studies of Medicare patients discharged to home health care in 2015–2016, 54% of all hospitalizations [ 17 ] and 73% of patients with a diabetes-related stay [ 18 ] received home health care within two weeks of discharge. Racial/ethnic disparities in post-acute referral and utilization of home health care were observed in both studies for non-Hispanic Black, Asian American/Pacific Islander (AAPI), American Indian/Alaska Native (AIAN), and Hispanic patients compared to (non-Hispanic) WHITE patients [ 17 , 18 ]. Efforts are ongoing to standardize institutional processes using clinical decision tools for referral decisions during the discharge planning and to prioritize home health visits at the agency level [ 12 , 19 ].…”

“…One example of this effort is in the State Innovation Models (SIM) initiatives of the CMS, wherein improving diabetes care is a priority in every state program [ 21 ]. Building directly on our earlier paper [ 18 ] examining predictors of hospital discharge to home health care and post-acute home health care use among Medicare beneficiaries with diabetes, this paper explores the following question: what is the relationship between delayed, late, or missed home health care and 30-day all-cause rehospitalizations.…”