Volume of Home- and Community-Based Services and Time to Nursing-home placement among Indiana Medicaid Waiver Recipients with Dementia

Volume of Homeand Community-Based Services and Time to Nursing-Home Placement Laura P. Sands,1 Huiping Xu,2 Joseph Thomas III,1, 3 Sudeshna Paul,4 Bruce A. Craig,1 ,Marc Rosenman2 Caroline C. Doebbeling,5 Michael Weiner,2, 6, 7, 1Purdue University 2Indiana University School of Medicine 3Regenstrief Center for Healthcare Engineering 4Harvard Medical School 5MDwise Hoosier, Indianapolis 6Indiana University Center for Health Services and Outcomes Research 7Regenstrief Institute, Inc. 8Health Services Research and Development Service Objective: The purpose of this study was to determine whether the volume of Homeand CommunityBased Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients’ risk of transitioning from longterm care provided through HCBS to long-term care provided in a nursing home. Data Sources: Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs. Study Design: Enrollees in Indiana Medicaid’s Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk. Principal Findings: Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77–0.99). Conclusions: Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.