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.

项目摘要 每年，超过20％的医疗保险受益人至少被送往医院，这些 住院通常标志着更复杂的医疗保健需求的开始和下降的轨迹 健康。住院后，超过40％的医疗保险受益人在出院后接受急性后护理（PAC）， 其中有90％的人要么从家庭健康机构谨慎地去熟练的护理设施（SNF）或家中。这 PAC时期通常对于影响随后的利用轨迹和较旧的结果至关重要 成年人，例如入院，长期疗养院入境和死亡率。与人在一起的人 阿尔茨海默氏病和相关痴呆症（ADRD）住院的可能性是没有 ADRD更有可能使用PAC，并且更有可能遭受院后并发症。 最近的Medicare付款改革，例如负责任的护理组织和捆绑的付款，已有 激励了减少机构PAC服务的使用和持续时间，以支持家庭服务， 即使对于ADRD患者。从这种转变向基于家庭的PAC转变的不良结果的证据混合在一起， 通过一些研究表明，根据家庭护理，对医院的再入院率提高。无论 当家庭提供支持时，基于家庭的PAC会产生更好的结果，社区环境是 一个关键但未解决的问题。适用于双重招收医疗保险和医疗补助（双重）的老年人， 一个特别脆弱的人口，占医疗保险和医疗补助的份额不成比例的 支出，这些支持通常由医疗补助以家庭和社区服务的形式资助 （HCB），近几十年来迅速发展。医疗补助HCB可能会更传统 在PAC时期，Medicare资助的家庭基于家庭，从而实现了更好的结果。医疗补助也可能 HCBS减少了使用机构PAC来支持家庭护理。 我们建议使用严格的准实验方法来估计补充Medicare- 用HCB资助PAC，这是为PAC提供和政策提供迫切需要的。我们将使用县 - 纵向仪器变量框架中医疗补助资助的HCBS可用性的年级变化 调查医疗补助资助的HCB（总体以及按类型和强度）在Medicare资助的PAC中的作用 利用和结果（医院的再入院，急诊室就诊，死亡率，长期护理 较旧的（65）双二元组的房屋入口和支出）。我们将根据ADRD状态对所有分析进行分层，以反映事实 该家庭护理对于ADRD患者可能更具挑战性，可能需要不同的组合或 服务强度以最大化结果。这项研究的结果将有助于回答一个关键问题 是否补充HCB的家庭PAC是否可以减少机构PAC并改善患者 结果，并将更广泛地为与PAC收益有关的政策提供信息。