Predictors of low-care prevalence in Florida nursing homes: the role of Medicaid waiver programs.

PURPOSE OF THE STUDY To examine the relationship between county-level Medicaid home- and community-based service (HCBS) waiver expenditures and the prevalence of low-care residents in Florida nursing homes (NHs). DESIGN AND METHODS The present study used a cross-sectional design. We combined two data sources: NH facility-level data (including characteristics of the facility and its residents) and county-level market characteristics (including HCBS waiver expenditures) for 653 Florida NHs in 2007. Low-care was defined as residents who require no physical assistance in any of the 4 late-loss activities of daily living (bed mobility, toileting, transferring, and eating). We estimated a 2-level hierarchical linear model (HLM) to examine the relationship between Medicaid HCBS waiver expenditures and the prevalence of low-care residents while accounting for resident assessment, facility-, and county-level covariates. RESULTS All Florida counties offered 2 statewide waivers, and 33 counties offered one or more of the 4 regional Medicaid HCBS waivers in 2007. Per-month beneficiary expenditures ranged from $755 to $1,778. The average Florida NH had 120 beds, and 8.0% of its residents were classified as low-care. Results from the HLM model showed that a $10,000 increase in per-enrollee HCBS waiver expenditures was associated with a 3.5 percentage point reduction in low-care resident prevalence (p = .03). IMPLICATIONS The findings suggest that Medicaid HCBS waiver programs may reduce the prevalence of low-care residents in NHs. Future studies should evaluate whether Medicaid HCBS waiver programs are effective in promoting community-living among low-care residents and mitigating the growth in long-term care expenditures.