Post‐acute care transitions and outcomes among Medicare beneficiaries with dementia: Associations with race/ethnicity and dual status

Abstract

Objective To evaluate how post‐acute care (PAC) transitions affect minority older adults with Alzheimer's disease or related dementia (ADRD), and the extent to which dual Medicare‐Medicaid eligibility may attenuate or exacerbate disparities in PAC outcomes. We examined: (1) PAC referrals by race/ethnicity and dual status; (2) individual, hospital, and market‐level factors associated with PAC; (3) the association between PAC and outcomes. Data Sources/Study Setting We used the following secondary data: Master Beneficiary Summary File (MBSF), Medicare Provider Analysis and Review (MedPAR), Minimum Data Set (MDS), Area Health Resource File (AHRF), hospital Provider of Services (POS) file, and the area deprivation index (ADI). Study Design This observational study consisted of 619,262 community‐residing Medicare fee‐for‐service (FFS) beneficiaries with ADRD who had a hospital stay in 2017. Data Collection/Extraction Methods PAC discharge was to skilled nursing facilities (SNF), home health care (HHC) agencies or home without services. Outcomes were 30‐day readmission and death. Multinomial logistic regressions with hospital random effects (RE), stratified by dual eligibility, were fit. Principal Findings Dual‐related differences were significantly larger than race/ethnicity differences in PAC transitions. For example, the difference in the probability of SNF transitions between White and Black patients was 3.2% and 6.8%‐points for non‐duals and duals, respectively. The difference between non‐dual/dual White patients was 21.6% points, and among Black patients 18.0%‐points. The adjusted risk of 30‐day readmission was 5.6 percentage point higher among non‐duals discharged to SNF, compared to home, but such risk among duals was not statistically significantly different. The adjusted probabilities of 30‐day mortality were larger for duals and non‐duals who transitioned to SNF, compared to those discharged home. Conclusions PAC referrals and the resulting outcomes for Medicare beneficiaries with ADRD are associated with multi‐level variables that need to be incorporated in discharge decision making.

Post‐acute care transitions during COVID‐19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia

“…However, despite the greater reduction in SNF use among racial and ethnic minoritized groups and duals, the substitution of SNF with HHA services was lower among these patients, particularly duals. Before the pandemic, duals with ADRD were more likely to utilize SNFs than non‐duals 12 . It is important to note that duals were also eligible to receive Medicaid‐paid home‐ and community‐based services (HCBS), offering a variety of medical and social services.…”

“…Prior to the pandemic, patients with ADRD tended to use SNF more frequently than other PAC services 5,8–11 . Furthermore, PAC trajectories among Medicare beneficiaries with ADRD have been shown to vary by race, ethnicity, and dual status 12 . Studies have documented racial and ethnic differences in access to nursing homes (NHs), including SNF 13–15 .…”

Experiences of in‐hospital care among dementia caregivers in the context of high neighborhood‐level disadvantage

“…Neighborhood‐level factors may hold implications for transitional care education and caregiver support surrounding hospitalizations. Community‐dwelling PLWD residing in areas of high neighborhood‐level disadvantage are less likely to discharge to a SNF following hospitalization 30 . Family caregivers provide considerable unpaid effort within SNFs, and these hardships may be experienced differently by caregivers across differing contexts 31 .…”

“…Communitydwelling PLWD residing in areas of high neighborhoodlevel disadvantage are less likely to discharge to a SNF following hospitalization. 30 Family caregivers provide considerable unpaid effort within SNFs, and these hardships may be experienced differently by caregivers across differing contexts. 31 Disparities may be exacerbated by documented discrepancies in caregiver training surrounding care transitions, with prior research demonstrating that caregivers who are Black, experiencing financial hardship, or caring for a Black, female, or Medicaid-enrolled patient are less likely to receive adequate training.…”

Examining the role of race and quality of home health agencies in delayed initiation of home health services for individuals with Alzheimer's disease and related dementias (ADRD)

“…The post‐hospitalization care transition to home is an especially vulnerable period for individuals with ADRD 10 . If adequate, appropriate, and timely post‐acute care (PAC) is not provided, the risk of unwarranted outcomes (e.g., re‐hospitalization) increases 11 .…”