Caregiving after discharge from the hospital

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PROJECT SUMMARY Caregiving burden is a large and growing concern in the United States. The burden of caregiving is even greater when the care recipient has Alzheimer's disease or related dementias (ADRD). Older adults are often in particular need of assistance after hospitalization, during the post-acute period. This care has frequently been provided in inpatient post-acute care settings, such as skilled nursing facilities (SNFs). Close to 20% of hospital discharges go to a SNF and Medicare spent over $600 billion on post-acute care in 2015. Among persons with dementia, the percentage of people discharged to SNFs for post-acute care is more than double (48%), compared to the overall rate. Despite the large spending on SNFs, the value of inpatient post-acute care to patients is uncertain. As a result, reducing its use has been a common target for payers such as Medicare, particularly under alternative payment models that tie financial incentives to improving value and reducing the costs of health care. Alternative payment models, such as bundled payment initiatives, have thus resulted in a declining use of SNFs in the post-acute period. The shift toward discharging more patients directly home after hospitalization may come at the expense of caregivers and families, however, particularly for families of persons with dementia. This raises substantial concern about associated consequences, including the increased amount of needed caregiving (both the frequency and intensity of caregiving) and potential loss of work productivity due to these increased caregiving demands. Evaluating the impact of this shift on caregiving is essential to gain a more complete understanding of the full costs of the increase in home-based post-acute care. Our overall objective is to examine changes in caregiving in the post-acute period, particularly among persons with dementia, as the use of inpatient post-acute care declines in the context of payment reform. We will do so by combining several datasets (surveys and Medicare claims from 2011-2019) that contain detailed information on caregiving during the post-acute period. Our specific aims are to describe trends in the frequency, intensity, and total amount of caregiving in the post-acute period and the characteristics of care recipients and their caregivers; to estimate changes in the frequency, intensity, and total amount of caregiving during the post-acute period associated with implementation of bundled payment initiatives; and to explore changes in work productivity among those who care for a family member (captured via use of family medical leave) associated with bundled payment implementation. The results from this study will provide empirical evidence regarding how the declining use of SNF has impacted caregiving in the post- acute period.