Utilization and Functional Outcomes Among Medicare Home Health Recipients Varied Across Living Situations

Abstract

BACKGROUND/OBJECTIVES Home health (HH) is a major type of home‐based skilled care available to Medicare beneficiaries. We examined the association between living situation (home alone, home with others, and assisted living (AL) residence) and utilization and functional outcomes among Medicare HH recipients. DESIGN Analysis of national data from the Outcome and Assessment Information Set, HH Compare, Medicare claims, and Area Health Resource Files. SETTING Medicare‐certified HH agencies in the United States. PARTICIPANTS National population of Medicare beneficiaries ≥65 years old who received HH care in CY 2017 (N = 6,637,496). MEASUREMENTS Outcomes included time‐to‐event measures of hospitalization and emergency department (ED) visits, and improvement in activities of daily living (ADL) from the start to the end of the HH admission. RESULTS AL residents (12%) and patients living alone at home (24%) had longer survival time without hospitalization and ED visits than patients living with others at home (64%). Adjusting for covariates and HH agency‐level random effects, and compared with patients living with others, AL residents had lower risk of hospitalization (hazard ratio (HR) = 0.85, P < .001) and ED visit (HR = 0.92, P < .001); however, less ADL improvement (β = 0.29 (29% less of total independence in one ADL)); and patients living alone had lower risk of hospitalization (HR = 0.94, P < .001) and ED visit (HR = 0.93, P < .001), yet more ADL improvement (β = −0.15 (15% more of total independence in one ADL)). CONCLUSION In the national population of Medicare HH recipients, patients living with others at home had the highest risk of hospitalization and ED visits, whereas AL residents had the lowest risk of hospitalization and patients living alone at home had the lowest risk of ED visits, meaning that combined support from HH and AL reduces acute care admissions. Evidence‐based interventions are needed for HH patients living with others at home to avoid unnecessary acute care use.

Risk factors for inpatient facility admission among home health care patients with diabetes

“…Second, community-dwelling patients with diabetes were more often alert and oriented and had better ADL performance than those in AL. This is consistent with common reasons for moving into AL and with past findings in HHC patients ( Nazareno et al, 2020 ; Wang et al, 2021 ). Lastly, HHC patients with diabetes in AL were more likely to have an unhealed pressure ulcer/injury.…”

“…Clinicians recorded patients’ abilities to complete nine ADL activities, each rated on a Likert-type scale ranging from independent to totally dependent/unable to complete. A composite score was calculated based on an established formula that accounts for the different number of potential responses on each ADL activity item and is more accurate than using raw scores ( Asiri et al, 2014 ; Fortinsky et al, 2003 ; Scharpf & Madigan, 2010 ; Wang et al, 2021 ). The ADL composite score ranges from 0 (total independence) to 9 (totally dependent/unable to complete).…”

“…Timely HHC services (skilled nursing care and physical, occupational, and speech therapy) may reduce the risk of hospitalization (Smith et al, 2021b), but HHC patients with diabetes are still three times as likely to be hospitalized compared to HHC patients without diabetes ( Fortinsky et al, 2006 ). Although HHC has primarily been provided for community-dwelling patients within their homes, it is increasingly provided for patients in residential supportive care settings such as assisted living (AL) ( Nazareno et al, 2020 ; Wang et al, 2021 ). Preventing inpatient admissions is a priority because older adults often experience declines in physical function while hospitalized or when admitted to a nursing home ( Covinsky et al, 2003 ; Masciocchi et al, 2019 ).…”

“…HHC patients in AL tend to be older and have greater impairments in cognition and activities of daily living (ADLs) than HHC patients living in the community ( Nazareno et al, 2020 ). While their cognitive and physical function place them at higher risk for inpatient admission, they also receive services in AL that may be protective ( Nazareno et al, 2020 ; Wang et al, 2021 ). In addition, AL residents are more likely to use home health services for health maintenance rather than following an acute hospitalization ( Nazareno et al, 2020 ).…”

Home Health Agencies With More Socially Vulnerable Patients Have Poorer Experience of Care Ratings

“…HHC clinicians also coordinate care of the patients with other providers, such as primary care providers and hospitalists (CMS, 2015). Abundant evidence has shown that HHC improves physical function, promotes quality of life, and reduces hospitalizations among older adults (Brody et al, 2016; Madigan et al, 2012; Osakwe et al, 2019; Wang, Ying, et al, 2020; Wang et al, 2020; Wang, Yu, et al, 2020; Wang et al, 2021b).…”