The Role of Medicaid HCBS in the Post-Acute Period

项目摘要 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需求的开始，以及 健康。超过40%的医疗保险受益人在出院后接受急性后护理(PAC)，以及 其中90%的人要么去熟练的护理机构(SNF)，要么在家庭健康机构的照顾下回家。这个 PAC周期通常是影响老年人随后的利用轨迹和结果的关键 成人，如再次入院、长期入住养老院、死亡率等。有以下情况的人 阿尔茨海默病和相关痴呆症(ADRD)住院的可能性是非阿尔茨海默病患者的两倍 ADRD患者更有可能使用PAC，也更容易出现住院后并发症。 最近的医疗保险支付改革，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，转而支持基于家庭的服务， 即使对于ADRD患者也是如此。关于这种向以家庭为基础的PAC转变的不利后果的证据喜忧参半， 一些研究表明，在家庭护理下，医院的再住院率有所增加。是否 当在家庭和社区环境中提供支持时，基于家庭的PAC会产生更好的结果 一个关键但尚未回答的问题。对于同时参加联邦医疗保险和医疗补助(DUAL)的老年人， 在医疗保险和医疗补助中占不成比例比例的特别脆弱的人群 在支出方面，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)，近几十年来发展迅速。医疗补助HCBS可能会补充更传统的 在PAC期间，医疗保险资助的家庭为基础，实现更好的结果。也有可能是医疗补助计划 HCBS减少了机构PAC的使用，转而支持基于家庭的护理。 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效应。 与母婴健康服务共同资助了政府账目委员会，这是为政府账目委员会的规定和政策提供信息所急需的。我们将使用县- 纵向工具变量框架中医疗补助资助的六氯联苯可用性的年水平变化 调查医疗补助资助的HCBS(总体和按类型和强度)在医疗保险资助的PAC中的作用 利用情况和结果(重新入院、急诊室就诊、死亡率、长期护理 对于年龄较大(65岁以上)的二人组来说，家庭入场券和支出)。我们将根据ADRD的地位对所有分析进行分层，以反映事实 对于ADRD患者来说，基于家庭的护理可能更具挑战性，可能需要不同的组合或 服务强度，以最大限度地提高结果。这项研究的结果将有助于回答以下关键问题 使用六氯联苯补充家庭PAC是否既能减少机构PAC，又能改善患者 结果，并将更广泛地为与PAC利益相关的政策提供信息。

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.