Home and Community-Based Service Use, Health Outcomes, and Health Care Costs for People with Alzheimer's Disease and Related Dementias

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Project Summary Millions of low-income older adults require long-term services and supports (LTSS) but coverage of LTSS by Medicare and private insurance is limited, leaving Medicaid as the primary payer for LTSS. In an effort to respect people's preference for aging in place and to save costs, state Medicaid programs have turned to policies designed to increase the use of home- and community-based services (HCBS), as an alternative to nursing home care. Under this push towards HCBS, people with Alzheimer's disease and related dementias (ADRD) have increasing opportunities to receive Medicaid HCBS. We propose to investigate HCBS use, health outcomes, and health care costs among people with ADRD, particularly those with both Medicare and Medicaid coverage. Although HCBS use has increased nationwide for the past decades, HCBS use rates vary substantially across states, suggesting the potential importance of state policies to encourage HCBS use. For example, state Medicaid programs have different financial/functional eligibility and enrollment caps for HCBS users. However, little is known about how these elements of state policies are associated with HCBS use. As state Medicaid programs strive to increase HCBS use, there is a need for robust evidence about how different state Medicaid policies are associated with HCBS use for people with ADRD. Despite state Medicaid programs' push towards HCBS, these type of services may not be optimal for all people with ADRD. HCBS use may meet people's preference for aging in place, but as people's ADRD progresses, they may need more intensive round-the-clock care. Therefore, HCBS use for these people may lead to lower- intensity care than needed, worse health outcomes, and higher health care costs (as a result of worse health outcomes). Our long-term goal is to identify elements of state Medicaid HCBS policies associated with an increase in HCBS use by people with ADRD as well as to assess when HCBS is appropriately used to keep them safe in the community. This proposal has four aims. First, we describe any use of HCBS, health outcomes (hospitalization, emergency department visits, and falls), and health care costs for people with ADRD over time (2016-2020) and across states. Second, we assess the association of state Medicaid HCBS policies with any use of HCBS among people with ADRD. Third, we assess the effect of HCBS use on health outcomes for people with ADRD across different levels of health status. Fourth, we assess the effect of HCBS use on health care costs for people with ADRD across different levels of health status. The proposed research will provide critical information about HCBS use, health outcomes, and health care costs for people with ADRD. This knowledge will help inform state Medicaid policymakers who are seeking the most effective approach towards HCBS and ultimately improve health outcomes for people with ADRD.