The Role of Medicaid HCBS in the Post-Acute Period

医疗补助 HCBS 在急性期后的作用

• 批准号: 10095390
• 负责人: RITA TAMARA KONETZKA
• 金额: $ 187.64万
• 依托单位: UNIVERSITY OF CHICAGO
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-09-15 至 2024-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10095390
• 关键词: Acute; Alzheimer' s Disease; Alzheimer' s disease related dementia; Caring; Case Management; Complement; Complex; County; Data; Dementia; Elderly; Emergency department visit; Enrollment; Evolution; Funding; Health; Health care facility; Healthcare; Home Care Services; Home Health Agency; Home environment; Hospitalization; Hospitals; Incentives; Inpatients; Length of Stay; Link; Long-Term Care; Medicaid; Medicare; Medicare claim; Medicare/Medicaid; Methods; Modification; Nursing Homes; Outcome; Patient-Focused Outcomes; Patients; Persons; Policies; Probability; Role; Self Care; Services; Skilled Nursing Facilities; Transportation; Variant; Vulnerable Populations; Work; acute care; adverse outcome; base; beneficiary; bundled payment; care outcomes; care systems; community based service; community setting; cost; functional status; home based service; hospital readmission; improved; mortality; payment; readmission rates

Project Summary Every year, more than 20% of Medicare beneficiaries are admitted to the hospital at least once, and these hospitalizations often mark the beginning of more complex health care needs and a trajectory of decline in health. More than 40% of Medicare beneficiaries receive post-acute care (PAC) after a hospital discharge, and 90% of those go either to a skilled nursing facility (SNF) or home with care from a home health agency. The PAC period is often critical in influencing the subsequent trajectory of utilization and outcomes for older adults, such as readmission to the hospital, long-term nursing home entry, and mortality. Persons with Alzheimer's Disease and Related Dementias (ADRD) are twice as likely to be hospitalized as those without ADRD, are more likely to use PAC, and are more likely to suffer post-hospitalization complications. Recent Medicare payment reforms, such as Accountable Care Organizations and bundled payments, have incentivized a reduction in the use and duration of institutional PAC services in favor of home-based services, even for patients with ADRD. Evidence on adverse outcomes from this shift toward home-based PAC is mixed, with some studies showing increased rates of readmission to the hospital under home-based care. Whether home-based PAC results in better outcomes when supports are available in the home and community setting is a critical but unanswered question. For older adults who are dually enrolled in Medicare and Medicaid (duals), a particularly vulnerable population who account for a disproportionate share of both Medicare and Medicaid spending, these supports are often funded by Medicaid in the form of home- and community-based services (HCBS), which has grown rapidly in recent decades. Medicaid HCBS may complement more traditional Medicare-funded home-based in the PAC period, enabling better outcomes. It is also possible that Medicaid HCBS decreases the use of institutional PAC in favor of home-based care. We propose to use rigorous quasi-experimental methods to estimate causal effects of supplementing Medicare- funded PAC with HCBS, which are critically needed to inform PAC provision and policy. We will use county- year-level variation in Medicaid-funded HCBS availability in a longitudinal instrumental variables framework to investigate the role of Medicaid-funded HCBS (overall and by type and intensity) in Medicare-funded PAC utilization and outcomes (readmissions to the hospital, emergency room visits, mortality, long-term nursing home entry, and spending) for older (65+) duals. We will stratify all analyses by ADRD status to reflect the fact that home-based care may be more challenging for people with ADRD and may require a different mix or intensity of services to maximize outcomes. Results from this study will help answer the critical question of whether supplementing home-based PAC with HCBS can both reduce institutional PAC and improve patient outcomes, and will inform policy related to PAC benefits more broadly.

项目概要 每年，超过 20% 的医疗保险受益人至少入院一次，而这些 住院治疗往往标志着更复杂的医疗保健需求的开始以及死亡率下降的轨迹 健康。超过 40% 的 Medicare 受益人在出院后接受急性期后护理 (PAC)，并且 其中 90% 的人要么去专业护理机构 (SNF)，要么回家接受家庭健康机构的护理。这 PAC 周期通常对于影响老年人的后续利用轨迹和结果至关重要 成人，例如再次入院、长期进入疗养院和死亡率。患有以下疾病的人 阿尔茨海默氏病和相关痴呆症 (ADRD) 住院的可能性是没有患阿尔茨海默病和相关痴呆症的人的两倍 ADRD 更有可能使用 PAC，并且更有可能出现住院后并发症。 最近的医疗保险支付改革，例如责任医疗组织和捆绑支付，已经 鼓励减少机构 PAC 服务的使用和持续时间，转而采用家庭服务， 即使是 ADRD 患者。关于这种向家庭 PAC 转变带来的不利后果的证据好坏参半， 一些研究表明，在家庭护理下重新入院的比率有所增加。无论 当家庭和社区环境中提供支持时，以家庭为基础的 PAC 会产生更好的结果 一个关键但尚未解答的问题。对于双重加入 Medicare 和 Medicaid (duals) 的老年人， 特别脆弱的人群，他们在医疗保险和医疗补助中所占的份额不成比例 支出，这些支持通常由医疗补助以家庭和社区服务的形式提供资金 （HCBS），近几十年来增长迅速。医疗补助 HCBS 可能会补充更传统的 PAC 期间由医疗保险资助的居家治疗，可实现更好的结果。医疗补助也有可能 HCBS 减少了机构 PAC 的使用，转而采用家庭护理。 我们建议使用严格的准实验方法来估计补充医疗保险的因果影响 与 HCBS 一起资助 PAC，这对于了解 PAC 条款和政策至关重要。我们将使用县- 纵向工具变量框架中医疗补助资助的 HCBS 可用性的年度变化 调查医疗补助资助的 HCBS 在医疗保险资助的 PAC 中的作用（总体以及按类型和强度） 利用和结果（再次入院、急诊室就诊、死亡率、长期护理 年龄较大（65 岁以上）双打的家庭入场费和支出）。我们将按 ADRD 状态对所有分析进行分层，以反映事实 家庭护理对于 ADRD 患者来说可能更具挑战性，可能需要不同的组合或 服务强度，以最大限度地提高成果。这项研究的结果将有助于回答以下关键问题： 用 HCBS 补充家庭 PAC 是否可以减少机构 PAC 并改善患者状况 成果，并将更广泛地为与 PAC 福利相关的政策提供信息。