Social Vulnerability and Medical Complexity Among Medicare Beneficiaries Receiving Home Health Without Prior Hospitalization

Abstract

Background and Objectives Recent Medicare home health payment changes reduce reimbursement for care provided to patients without a preceding hospitalization. Beneficiaries may enter home health without a preceding hospitalization via referral from a community provider or through incurring multiple episodes of home health care. We assess potential implications of this change by examining characteristics of patients accessing Medicare home health through each of these pathways. Research Design and Methods Nationally-representative retrospective cohort study of 1,224 (weighted n=5,913,080) older adults who participated in the National Health and Aging Trends Study (NHATS) between 2011-2015, and received Medicare-funded home health within one year of interview. Patient characteristics before home health were drawn from NHATS while characteristics during home health, referral source, and number of episodes incurred were drawn from linked Outcomes and Assessment Information Set (OASIS) and Medicare claims. We tested for differences in characteristics by referral source and number of episodes using weighted chi-squared tests and t-tests. Results Patients referred to home health from the community were more than twice as likely to be Medicaid-enrolled (24.0% vs 12.5%, p<0.001), have dementia (29.5% vs 12.4%, p<0.001), and have received 80+ hours/month of family caregiver assistance (20.7% vs 10.1%, p<0.001) prior to home health entry compared to those referred from a hospital or skilled nursing facility. Patients who incurred multiple episodes in a spell of home health care were more likely to have high clinical severity during home health (48.3% vs 28.1%, p<0.001), compared to those with a single episode. Discussion and Implications Greater social vulnerability and care needs before home health were associated with community referral, while greater clinical severity during home health was associated with incurring multiple episodes of care. Findings suggest that recent payment changes may threaten home health access among beneficiaries with greater social vulnerability and/or medical complexity.

Cognitive impairment associated with greater care intensity during home health care

“…10,34 Compared to those without cognitive impairment, cognitively impaired Medicare beneficiaries access HHC at higher rates 35 and using different referral pathways. 22 During HHC they require greater family caregiver support 36 and a greater number of visits (particularly skilled nursing visits). These differences are especially notable given that cognitively impaired patients face a higher risk of readmission during HHC 37 and greater visit intensity is linked to reduced likelihood of readmission and other unplanned facility admission for this population.…”

“…Compared to those without cognitive impairment, cognitively impaired Medicare beneficiaries access HHC at higher rates 35 and using different referral pathways 22 . During HHC they require greater family caregiver support 36 and a greater number of visits (particularly skilled nursing visits).…”

“…First, billing/claims data routinely underestimate the presence of cognitive impairment in older adults 19,20 . Second, it is more precise to use a measure of cognitive impairment collected during HHC as deteriorations in cognition often precede HHC use as a result of hospitalization 21 or as a precipitating factor for HHC referral 22 . Third, as this item is already routinely collected during Medicare‐funded HHC, it could easily be incorporated into potential revisions to the Medicare home health payment system.…”

“…First, episodes not immediately preceded by a hospitalization receive lower reimbursement under PDGM. These include episodes prompted by a community referral-which prior research finds are more common among older adults with cognitive impairment 22,35 as well as later episodes during a sustained period of HHC use. In this study, we find that HHC patients with cognitive impairment have significantly higher odds of incurring multiple successive episodes.…”

Patient cognitive impairment associated with higher home health care delivery costs

“…14 Yet, with the exception of a comorbidity category for patients who have both a dementia diagnosis and a pressure ulcer, PDGM does not adjust for the presence of cognitive impairment. 14 Simultaneously, PDGM reduces reimbursement for patterns of home health utilization, which are more common among those with cognitive impairment, including entering home health without an immediately preceding hospitalization, 15 receiving services during the latter half of a home health episode, 16 and incurring multiple successive home health episodes. 16,17 In the past, home health agencies have been highly responsive to Medicare payment system revisions, leading to reduced home health access for beneficiaries with greater disability, clinical severity, and social vulnerability.…”